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THE 

DISEASES OF INFANCY 
AND CHILDHOOD 

FOR THE USE OF STUDENTS 
AND PRACTITIONERS OF MEDICINE 

BY 

L EMMETT HOLT, M.D., Sc.D., LLD. 

PROFESSOR OF DISEASES OF CHILDREN IN THE COLLEGE OF PHYSICIANS AND SURGEONS 

(COLUMBIA UNIVERSITY), NEW YORK; ATTENDING PHYSICIAN TO THE BABIES' 

AND FOUNDLING HOSPITALS, NEW YORK; CORRESPONDING MEMBER OF 

THE GESELLSCHAFT FUR INNERE MEDIZIN UND KINDERHEILKUNDE, 

VIENNA, AND HONORARY MEMBER OF THE GESELLSCHAFT 

FUR KINDERHEILKUNDE, GERMANY 

AND 

JOHN HOWLAND, A.M., M.D. 

PROFESSOR OF PEDIATRICS IN THE JOHNS HOPKINS UNIVERSITY, BALTIMORE; 

DIRECTOR OF THE HARRIET LANE HOME; PEDIATRICIAN-IN-CHIEF TO 

THE JOHNS HOPKINS HOSPITAL; CORRESPONDING MEMBER OF 

THE GESELLSCHAFT FUR INNERE MEDIZIN UND 

KINDERHEILKUNDE, VIENNA 




SEVENTH EDITION, FULLY REVISED 

WITH TWO HUNDRED AND FIFTEEN ILLUSTRATIONS 



NEW YORK AND LONDON 

D. APPLETON AND COMPANY 

1916 



-RJ* 5 






Copyright, 1897, 1902, 1905, 1907, 1909, 1911, 1916, 
By D. APPLETON AND COMPANY 



OCT II 1916 
Oci:W"88887 

Printed in the United States of America 






PREFACE TO THE SIXTH EDITION. 



In the preparation of this edition the author has associated with 
him Dr. John Howland, his former assistant, who will hereafter be 
connected with the work as joint author. 

Progress along many lines in paediatrics has been rapid during the 
last two )'ears. To make room for new knowledge without unduly 
enlarging the size of the volume has made it necessary to cut out about 
seventy-five pages of old material. It is believed that this has been 
accomplished without impairing the value of the chapters which have 
been abridged. The decision of the publishers to make entirely new 
plates has made this comparatively easy. 

There is scarcely a page in the book which has not been subject to 
some revision. Many articles have been entirely rewritten and several 
new ones appear for the first time in this edition. The greater part of 
the new material will be found in the chapters upon Nutrition and 
Infant Feeding, Infant Mortality, Intestinal Intoxication, Pyloric Ste- 
nosis, Appendicitis, Acute Peritonitis, Endocarditis and Pericarditis, 
Cerebro-spinal and Other Forms of Acute Meningitis, Acute Poliomye- 
litis, Hereditary Syphilis and Tuberculosis. 

A number of the old illustrations have been omitted as no longer 
necessary; others have been replaced by better ones. In all, thirty-six 
new illustrations have been introduced, including twelve radiographs. 
All illustrations are from original sources unless otherwise stated. 

The authors desire to acknowledge their indebtedness to Dr. F. H. 
Bartlett for much assistance rendered in every way in the work of 
revision; to Dr. H. H. Mason for correction of the proof sheets, and 
to Dr. N". C. Holt for the preparation of the index. 

14 West Fifty-fifth Street, 
New York. 



PREFACE TO THE SEVENTH EDITION 



In this Seventh Edition the authors have endeavored to bring the 
book abreast of the science of the day. In the five years which have 
elapsed since the last revision there have been great advances in our 
knowledge of many of the subjects which are considered in a general 
textbook upon Pediatrics. The endeavor has been made to introduce 
this new knowledge without greatly changing the general arrangement 
of the book. To do this without increasing the size of the volume has 
made it necessary to cut out nearly one hundred pages of old material, 
and to condense other portions of the book. It is believed that this 
has been done without impairing the value of the chapters which have 
been abridged. The decision of the publishers to make entirely new 
plates has made this comparatively easy. 

There is scarcely a page in the book but has been subjected to re- 
vision. Sixteen new articles appear for the first time in this edition. 
The more important ones are Acidosis, Xeuropathic and Exudative 
Diathesis, Cardiac Arrhythmia, Acute Lymphatic Leukemia, Banti's 
Disease, Osteogenesis Imperfecta, Still's Disease, Syphilis of the Xer- 
vous System, Pellagra, Epidemic Catarrh, Duodenal L T lcer, and Idiosyn- 
crasies to Food Stuffs. 

More than twenty chapters have been almost entirely rewritten, the 
most important being those upon Birth Paralyses. Milk and Infant 
Feeding, Digestion in Infancy, Chronic Intestinal Indigestion, Hirsch- 
sprung's Disease, Asthma, Accidental Heart Murmurs, Hydronephrosis, 
Gonococcus A^aginitis, Tetany, Convulsions, Epilepsy, Hydrocephalus, 
Poliomyelitis, Diseases of Ductless Glands, Diabetes, Hodgkin's Disease, 
and Tuberculous Adenitis. 

Many old illustrations have been omitted and fifteen new ones in- 
troduced, all of them from original sources. Especial attention has 
been devoted by the authors to the newer methods of diagnosis and 
treatment. 

The authors desire to acknowledge the assistance of Dr. X. Curtice 
Holt in the correction of the proof sheets and the preparation of the 
index. 

L. Emmett Holt, 
John Howland. 



CONTENTS 



PAET I 

CHAPTER PAGE 

I. — Hygiene and General Care of Infants and Young Children . 1 
Care of the newly-born child; bathing; clothing; care of the eyes; 
care of the mouth and teeth; care of the skin; care of the genital 
organs; vaccination; training to proper control of rectum and 
bladder; general hygiene of the nervous system; sleep; exercise; 
airing; the nursery; the nurse; the amount of air space required 
by infants; the care of premature and delicate infants; incubators; 
the feeding of the premature infant. 

II. — Growth and Development of the Body 15 

Weight; height; growth of extremities as compared with the 
trunk; the head; the chest; the abdomen; muscular development; 
development of special senses; speech; dentition. 

III. — Peculiarities of Disease in Children . . . . .30 

Etiology; symptomatology and diagnosis; pathology; prognosis 
and infant mortality; prophylaxis; therapeutics. 



PAET II 

Section I. — Diseases of the Newly Born 

I. — Asphyxia 69 

II. — Congenital Atelectasis 74 

III. — Icterus 77 

IV. — The Acute Infections of the Newly Born 82 

The acute pyogenic diseases; ophthalmia; tetanus; epidemic 
hemoglobinuria; fatty degeneration of the newly born; pemphigus. 

V. — Hemorrhages 96 

Traumatic or accidental hemorrhages; spontaneous hemorrhages. 

VI. — Birth Paralyses 106 

Cerebral paralysis; facial paralysis; brachial paralysis. 

ix 



x CONTENTS 

CHAPTER PAGE 

VII. — Tumors of the Umbilicus, Mastitis, etc. 114 

Umbilical hernia; mastitis; intestinal obstruction; diaphragmatic 
hernia; congenital stridor; sclerema; inanition fever. 



Section II. — Nutrition 

I. — Introductory 127 

The food constituents and the purposes they subserve in nutrition. 

II. — The Infant's Dietary .' 134 

Woman's milk; cow's milk; top milk — skimmed milk; milk sterili- 
zation; commercial pasteurization of milk; pasteurization vs. 
sterilization; methods of heating milk; frozen milk; peptonized 
milk; condensed milk; dried milk; buttermilk and other forms 
of fermented milk; protein milk; junket, curds and whey; beef 
preparations; cereals; infant foods. 

III. — Infant Feeding 165 

Choice of methods; breast feeding; maternal nursing; wet-nursing; 
weaning; mixed feeding; artificial feeding; formulas for whole 
milk ; schedule for healthy infants during the first year ; feeding in 
difficult cases. 

IV. — Feeding after the First Year 209 

Healthy infants during the second year; feeding from the third to 
the sixth year; feeding during acute illness; idiosyncrasies to food- 
stuffs; acidosis. 

V. — The Derangements of Nutrition 218 

Inanition; marasmus; malnutrition. 

VI. — Diseases Due to Faulty Nutrition . 231 

Scorbutus ; rickets. 

VII.— Diatheses 260 

The exudative diathesis; the neuropathic diathesis. 

Section III. — Diseases of the Digestive System 

I. — Diseases of the Lips, Tongue, and Mouth 267 

Malformations; diseases of the lips; diseases of the tongue; dental 
caries; alveolar abscess; difficult dentition; catarrhal stomatitis; 
herpetic stomatitis; ulcerative stomatitis; thrush; gonorrheal sto- 
matitis; syphilitic stomatitis; diphtheritic stomatitis; gangrenous 
stomatitis. 

II. — Diseases op the Pharynx . 288 

Aeulr pharyngitis; uvulitis; elongated uvulva; retropharyngeal 
abscess; adenoid vegetations of the vault of the pharynx. 



CONTENTS xi 

CHAPTER PAGE 

III. — Diseases of the Tonsils 300 

Membranous tonsillitis; ulceromembranous tonsillitis; follicular 

tonsillitis; phlegmonous tonsillitis; chronic hypertrophy of the 
tonsils. 

IV. — Diseases of the Esophagus 311 

Malformations; acute esophagitis; retro-esophageal abscess. 

V. — Diseases of the Stomach . - . . . . ' . . . . 315 
Digestion in infancy ; malformations and malpositions of the stom- 
ach; hypertrophic stenosis of the pylorus; vomiting; cyclic vomit- 
ing; acute gastritis; chronic gastric indigestion; dilatation of the 
stomach ; ulcer of the stomach ; duodenal ulcers ; tumors of the 
stomach; hemorrhage from the stomach; the swallowing of foreign 
bodies. 

VI. — Diseases of the Intestines 348 

Malformations and malpositions; diarrhea; acute intestinal indi- 
gestion and diarrhea. 

VII. — Diseases of the Intestines (continued) 373 

Acute ileocolitis — dysentery; amebic colitis; amyloid degeneration 
of the intestines; tuberculosis of the intestines and mesenteric 
lymph nodes. 

VIII. — Diseases of the Intestines (continued) 395 

Chronic intestinal indigestion; intestinal colic; chronic constipa- 
tion; hypertrophy and dilatation of the colon; intussusception. 

IX. — Diseases of the Intestines (continued) 418 

Appendicitis; intestinal worms. 

X. — Diseases of the Rectum 430 

Prolapsus ani; fissure of the anus; proctitis; ischiorectal abscess; 
rectal polypus; hemorrhoids; incontinence of feces. 

XI. — Diseases of the Liver 436 

Catarrhal jaundice; new growths; acute yellow atrophy; congestion 
of the liver; abscess of the liver — suppurative hepatitis; cirrhosis; 
amyloid degeneration; fatty liver; hydatids; biliary calculi. 

XII. — Diseases of the Peritoneum . . 444 

Acute peritonitis; chronic (non-tuberculous) peritonitis; tubercu- 
lous peritonitis; ascites; subphrenic abscess. 



Section IV. — Diseases on the Respiratory System 

I.— Nasal Cavities 457 

Acute rhinopharyngitis; chronic nasal catarrh; chronic rhinitis; 
cpistaxis. 



xii CONTENTS 

CHAPTER PAGE 

II. — Diseases of the Larynx . 465 

Catarrhal spasm of the larynx; acute catarrhal laryngitis; sub- 
mucous laryngitis — edema of the glottis; chronic laryngitis; new 
growths; foreign bodies in the larynx and bronchi. 

III. — Diseases of the Lungs 476 

The peculiarities of the lungs in infancy and early childhood; acute 
catarrhal bronchitis; fibrinous bronchitis; chronic bronchitis; 
asthma. 



IV. — Diseases of the Lungs (continued) 492 

Pneumonia; acute bronchopneumonia. 

V. — Diseases of the Lungs (continued) . 526 

Lobar pneumonia; pleuropneumonia; hypostatic pneumonia; 
chronic bronchopneumonia — chronic interstitial pneumonia — bron- 
chiectasis; abscess of the lung; gangrene of the lung; acquired 
atelectasis — pulmonary collapse; emphysema. 

VI. — Pleurisy 557 

Dry pleurisy; pleurisy with serous effusion; empyema. 



Section V. — Diseases of the Circulatory System 

I. — Peculiarities of the Heart and Circulation in Early Life . . 575 

II. — Congenital Anomalies of the Heart 579 

III. — Pericarditis 588 

Acute pericarditis; chrOnic pericarditis with adhesions. 

IV. — Endocarditis and Valvular Disease of the Heart .... 594 
Malignant endocarditis; myocarditis; accidental murmurs; func- 
tional disturbances of the heart; diseases of the blood vessels. 

Section VI. — Diseases of the Urogenital System 

I. — The Urine in Infancy and Childhood ..;.... 615 
Lordotic, orthostatic or cyclic albuminuria; hematuria; hemoglobi- 
nuria; pyuria; anuria; diabetes insipidus. 

II. — Diseases of the Kidneys 623 

Malformations and malpositions; uric-acid infarctions; chronic 
congestion of the kidney ; acute degeneration of the kidneys ; acute 
diffuse nephritis; chronic nephritis; tuberculosis of the kidney; 
tumors of the kidney; pyelitis — pyelocystitis ; renal calculi; perine- 
phritis. 



CONTENTS xiii 

CHAPTER PAGE 

III. — Diseases of the Genital Organs . . . . . . . . 650 

Malformations; diseases of the male genitals; diseases of the 
female genitals; gangrenous vulvitis. 

IV.— Enuresis 662 

Vesical calculus. 

Section VII. — Diseases of the Nervous System 
I. — Introductory 669 

II. — General and Functional Nervous Diseases ...... 671 

Convulsions ; tetany ; epilepsy ; chorea ; other spasmodic affections ; 
hysteria; headaches; disorders of speech; disorders of sleep; in- 
jurious habits of infancy and childhood. 

III. — Diseases of the Brain and Meninges 719 

Malformations; pachymeningitis; acute meningitis; cerebrospinal 
meningitis ; acute meningitis due to other causes ; tuberculous men- 
ingitis; chronic basilar meningitis in infants; thrombosis of the 
sinuses of the dura mater; cerebral abscess; cerebral tumor; hy- 
drocephalus; chronic internal hydrocephalus; infantile cerebral 
paralysis; amaurotic family idiocy; mental deficiency; Mongolian 
idiocy; deaf-mutism. 

IV. — Diseases of the Spinal Cord • . . . 796 

Malformations; spinal meningitis; myelitis; compression-myelitis; 
acute poliomyelitis; tumors of the spinal cord; hereditary ataxia, 
diseases associated with progressive wasting; congenital myatonia. 

V. — Diseases of the Peripheral Nerves 828 

Multiple neuritis; diphtheritic paralysis; facial paralysis. 

Section VIII. — Diseases of the Blood, Lymph Nodes, Ductless Glands, 

Bones and Joints 

I. — Diseases of the Blood 839 

Secondary anemia; chlorosis; pseudoleukemic anemia; pernicious 
anemia; leukemia; hemophilia; purpura. 

II. — Diseases of the Lymph Nodes . . 860 

Simple acute adenitis; simple chronic adenitis; syphilitic adenitis; 
tuberculous adenitis; Hodgkin's disease. 

III. — Diseases of the Ductless Glands • . . . 876 

The spleen; enlargement of the spleen; diseases of the thyroid; 
sporatic cretinism; hypothyroidism; Graves' disease; hyperthy- 
roidism; diseases of other ductless glands; diseases of the thymus; 
status lvmDhaticus. 



xiv CONTENTS 

CHAPTER PAGE 

IV. — Diseases of the Bones and Joints 896 

Osteogenesis imperfecta; chondrodystrophy; acute arthritis of in- 
fants; chronic arthritis; tuberculous diseases of the bones and 
joints. 

V. — Diseases of the Skin . . . 920 

Congenital ichthyosis; miliaria; seborrhea; eczema; f urunculosis ; 
gangrenous dermatitis; impetigo contagiosa; urticaria; scabies; 
tinea tonsurans — ringworm of the scalp. 

VI. — Diseases of the Ear . . . 938 

Acute otitis. 



I- 
II.- 

III.- 

IV.- 

V.- 

VI.- 

VII.- 

VIIL- 

IX, 

X, 

XI, 

XII, 

XIII, 



Section IX.- — The Specific Infectious 
-Scarlet Fever . 



-Mi 



-Rubella 

-Varicella 

-Vaccinia — Vaccination 

-Pertussis 

-Mumps 

-Diphtheria 

-Typhoid Fever . 

-Tuberculosis 

-Syphilis 

-Influenza . 

-Malaria 



Diseases 



952 



975 



. 991 
. 994 
. 997 
. 1003 
. 1015 
, 1020 
. 1059 
. 1067 
. 1103 
. 1130 
. 1139 



Section X. — Other General Diseases 

I. — Rheumatism 1149 

II. — Diabetes Mellitus . 1155 

III.— Pellagra 1158 

Index 1163 



LIST OF ILLUSTRATIONS 



PLATES 

PLATE FACING 

PAGE 

I. Chart showing by months the mortality of New York City for the 

different ages for three consecutive years ..... 44 
II. A, Costochondral junction in early rickets; B, Normal costochondral 

junction 244 

III. Typical rickets 248 

IV. Deformity of the chest in severe rickets 252 

V. Extensive superficial ulceration of the colon 376 

VI. Deep follicular ulcers of the colon . 378 

VII. Membranous inflammation of the ileum ....... 386 

VIII. Acute bronchopneumonia 498 

IX. Acute pleuropneumonia 546 

X. Chronic bronchopneumonia 548 

XI. Acute pneumococcus meningitis, complicating pleuropneumonia . . 744 

XII. A, Blood of an eight-months' fetus; B, Simple anemia; C, von 

Jaksch's anemia ; D, Acute lymphatic leukemia .... 840 

XIII. Tuberculosis of the tracheobronchial lymph nodes .... 1078 



ILLUSTRATIONS IN THE TEXT 

FIGURE 

1. Weight curve for the first twenty days 

2. Weight curve for the first year . 

3. Skull, showing premature ossification . 

4. Deaths, New York City, per 1,000 of population 

5. Deaths by months, New York City . 

6. Chief causes of death first year . 

7. Colon of a child six months old . 

8. Pemphigus neonatorum 

9. Triple cephalhematoma 

10. Meningeal hemorrhage of the newly born 

11. Erb's paralysis 

12. Umbilical fistula and tumors . 

13. Diaphragmatic hernia .... 

14. Temperature chart in inanition fever . 

15. Apparatus for examination of human milk 

xv 



PAGE 

16 

17 

23 

A\ 

45 

47 

65 

95 

98 

107 

112 

115 

119 

124 

139 






xvi LIST OF ILLUSTRATIONS 

FIGURE PAC E 

16. A, Babcock tubes; B, Lewi's modification for human milk . . . 140 

17. Chart showing effect of pregnancy on weight of nursing infant . . . 178 

18. Case of marasmus 223 

19. Case of scurvy 235 

20. Costochondral junction in marked rickets 247 

21. Rachitic skull, inside view . . 249 

22. Rachitic head 250 

23. Rachitic skull, external view 250 

24. Rachitic thorax in outline . 251 

25. Rachitic spine . 252 

26. Multiple fractures in rickets 253 

27. Epithelial desquamation of the tongue . . . . . . . 270 

28. Thrush 282 

29. Adenoid vegetations 295 

30. Temperature chart, streptococcus angina following measles . . . 303 

31. Gastric peristalsis in pyloric stenosis 323 

32. Malformations of the rectum 349 

33. Chart showing mortality from diarrheal diseases in New York . . 352 

34. Chart showing deaths under one year per 1,000 of population under 

one year, New York City, summer months 353 

35. Temperature chart of acute intestinal intoxication with fatal relapse . 362 

36. Acute catarrhal ileocolitis, severe form 376 

37. Follicular ulceration of the colon, early stage 378 

38. Follicular ulceration of the colon, later stage 379 

39. Membranous colitis 380 

40. Temperature chart in ileocolitis 383 

41. Temperature chart in membranous colitis . . . ... . 385 

42. Temperature chart in membranous colitis 386 

43. Chronic intestinal indigestion 396 

44. Ileocecal intussusception 411 

45. Mechanism of intussusception 413 

46. An air vesicle in bronchopneumonia 493 

47. An air vesicle in lobar pneumonia 494 

48. Bronchopneumonia with thickened bronchus 499 

49. Bronchopneumonia with emphysema ........ 501 

50. Bronchopneumonia, diffuse purulent infiltration 502 

51. Persistent bronchopneumonia . 504 

52. Temperature chart in mild uncomplicated bronchopneumonia . . . 509 

53. Temperature chart, prolonged bronchopneumonia 510 

54. Temperature chart, relapsing bronchopneumonia 510 

55. Temperature chart, rapidly fatal bronchopneumonia . . . . .511 

56-59. Physical signs in bronchopneumonia 513 

60. Temperature chart, persistent bronchopneumonia 515 



LIST OF ILLUSTRATIONS xvii 

FIGURE PAGE 

61. Temperature chart, bronchopneumonia following pertussis . . . 516 

62. Temperature chart, bronchopneumonia complicating influenza . . 518 

63. Bronchopneumonia — X-ray 520 

64. Temperature chart, typical lobar pneumonia . . . . . . 531 

65. Temperature chart, remittent type, lobar pneumonia 532 

66. Temperature chart, lobar pneumonia, subnormal temperature after crisis 532 

67. Temperature chart, abortive pneumonia , 533 

68-70. Physical signs, lobar pneumonia 536 

71. Lobar pneumonia — X-ray 537 

72. General subcutaneous emphysema . . . . . . . 557 

73. Section of lung, showing distribution of fluid in chest .... 564 

74. Empyema — X-ray . 565 

75. Empyema — X-ray . . 565 

76. Temperature chart, empyema following pneumonia 566 

77. Temperature chart, empyema following pneumonia 566 

78. Deformity after old empyema 572 

79. Apparatus for inducing pulmonary expansion after empyema . . . 573 

80. Congenital cardiac disease 581 

81. Clubbing of fingers in congenital cardiac disease 584 

82-83. Pericarditis with effusion — X-ray . . 591 

84. Congenital malformations of the kidneys and ureters . . . 626 

85. Sarcoma of the kidney ........... 641 

86. Tetany . 679 

87. Meningocele 720 

88. Encephalocele . . 720 

89. Hydrencephalocele 720 

90. Meningocele 720 

91. Frontal meningocele 721 

92. Nasofrontal meningocele 721 

93. Incidence of cerebrospinal meningitis 727 

94. Posture in cerebrospinal meningitis 731 

95. Temperature chart, cerebrospinal meningitis, recovery .... 735 

96. Temperature chart, cerebrospinal meningitis, treated by serum . . 739 

97. Temperature chart, cerebrospinal meningitis, with late injection of 

serum 740 

98. Seasonal occurrence of tuberculous meningitis 749 

99. Tracing of respiration in tuberculous meningitis 751 

100. Temperature chart in tuberculous meningitis 752 

101. Chronic basilar meningitis 755 

102. Chronic basilar meningitis 756 

103. Brain in external hydrocephalus 770 

104. Brain in internal hydrocephalus 771 

105. Section of a normal brain 772 

2 



xviii LIST OF ILLUSTRATIONS 

FIGURE PAGE 

106. Vertical transverse section of a brain in congenital hydrocephalus . . 774 

107. Oxycephaly with exophthalmus 777 

108. Scaphocephaly 778 

109. Brain showing atrophy 779 

110. Convulsions in spastic paraplegia 781 

111. Spastic paraplegia 782 

112. Recent meningeal hemorrhage 784 

113. Infantile hemiplegia showing contractures 786 

114. Brain in idiocy 791 

115-117. Various types of mental defect 792 

118-120. Mongolian idiocy 794 

121. Spina bifida, meningocele (partially diagrammatic) 797 

122. Spina bifida, meningocele 798 

123. Spina bifida, meningomyelocele (partially diagrammatic) . . . 798 

124. Spina bifida, sacral 800 

125. Infantile spinal paralysis of lower extremity 815 

126. Infantile spinal paralysis of shoulder 816 

127. Muscular pseudohypertrophy 825 

128. Alcoholic neuritis 830 

129. Diphtheritic paralysis 831 

130. Facial paralysis 836 

131. Acute suppurative adenitis, cervical 863 

132. Acute suppurative adenitis, inguinal . . ... . . . 864 

133. Cicatrices following tuberculous adenitis ....... 871 

134-135. Cretins, showing effect of thyroid treatment 883 

136-137. Cretins, showing effect of thyroid treatment 885 

138. Infantile myxedema 887 

139. Enlarged thymus 892 

140. Osteogenesis imperfecta — X-ray . . . 896 

141. Chondrodystrophy, radiograph of skull 898 

142. Chondrodystrophy, long bones 898 

143. Chondrodystrophy, infantile figure 899 

144. Chondrodystrophy, trident hand 899 

145. Chondrodystrophy, adult figure 899 

146. Section of the spine in Pott's disease 908 

147. Hip-joint disease 913 

148. Tuberculous dactylitis 919 

149. Congenital ichthyosis . . . 921 

150. Temperature chart, acute otitis, following influenza 940 

151. Temperature chart, acute otitis, early paracentesis 941 

152. Temperature charts in scarlet fever, mild cases 958 

153. Temperature chart in scarlet fever, typical curve 959 

154. Temperature chart in severe uncomplicated scarlet fever .... 960 



LIST OF ILLUSTRATIONS x i x 

FIGURE PAGE 

155. Temperature chart in fatal -septic scarlet fever 961 

156. Temperature chart in scarlet fever with late otitis 965 

157. Temperature chart in scarlet fever with late nephritis .... 966 
158-159. Temperature charts in measles, typical curve 981 

160. Temperature chart in measles, occasional course ...... 982 

161. Temperature chart in measles, prolonged course 982 

162-163. Temperature charts in measles complicated by pneumonia . . 983 
164. Table showing protective power of vaccination ...... 998 

165-169. Vaccination vesicles 1000 

170. Generalized vaccinia . 1001 

171. Temperature chart in typhoid fever, short course 1062 

172. Temperature chart in typhoid fever, with relapse 1062 

173. Tuberculous bronchopneumonia, diffuse consolidation .... 1076 

174. Cavity from tuberculous bronchopneumonia 1076 

175. Pulmonary tuberculosis, extensive caseation 1077 

176. Miliary tuberculosis of the lungs . 1085 

177. Temperature chart of tuberculosis following measles .... 1088 

178. Temperature chart of tuberculous bronchopneumonia, general tuber- 

culosis ... 1089 

179. Temperature chart of tuberculous bronchopneumonia with softening . 1090 

180. Tuberculous bronchial glands . . . . 1098 

181. Early eruption of hereditary syphilis, legs 1111 

182. Early eruption of hereditary syphilis, face 1112 

183. Syphilitic scaling of the sole 1112 

184. A later form of eruption in hereditary syphilis 1113 

185. Hereditary syphilis 1115 

186. Syphilitic periostitis of the fibula, radiograph 1115 

187-188. Syphilitic dactylitis 1116 

189-190. Syphilitic dactylitis, radiograph . . 1117 

191. Syphilitic notched teeth 1117 

192. Syphilitic teeth, deformed 1118 

193. Syphilitic osteoperiostitis of the tibia 1119 

194. Syphilitic osteoperiostitis of the tibia, radiograph 1120 

195. Temperature chart of severe influenza in an infant 1132 

196. Temperature chart of acute bronchopneumonia complicating influenza . 1133 

197. Temperature chart, influenza, bronchitis, otitis 1134 

198. Temperature chart, double tertian intermittent fever . . . .1141 

199. Temperature chart, tertian intermittent fever 1142 

200. Temperature chart in malaria, irregular type 1143 

201. Pellagra 1160 



THE DISEASES OF INFANCY AND 
CHILDHOOD 

PART I 



CHAPTER I 

HYGIENE AND GENERAL CARE OF INFANTS AND YOUNG 

CHILDREN 

The physical development of the child is essentially the product of 
the three factors — inheritance, surroundings, and food. The first of these 
it is beyond the physician's power to alter ; the second is largely and the 
third almost entirely within his control, at least in the more intelligent 
classes of society. These two subjects, infant hygiene and infant feeding, 
are the most important departments of pediatrics. 

The Care of the Newly-Born Child. — After the ligature of the cord the 
child should be wrapped in a thick blanket and placed in a warm room. 
In hospital practice the eyes should be cleansed with absorbent cotton and 
water which has been boiled, and then two or three drops of a two per 
cent solution of nitrate of silver, after Crede's method, instilled into each 
eye by means of a glass rod or eye-dropper. In private practice a ten per 
cent solution of argvrol may be substituted, unless the mother has had a 
purulent vaginal discharge, in which case the silver solution should 
always be used. The bath should now be given in a warm room ; the body 
being first oiled thoroughly in order to remove the vernix caseosa and 
then washed in water at a temperature of 100° F. The mouth should be 
cleansed with sterile water and a soft cloth, and no violence employed. 
The cord may be covered with sterilized talcum or bismuth powder, and 
wrapped in sterile gauze or surgeon's lint. The abdomen should now be 
enveloped in a flannel band, eight or ten inches wide, and pinned rather 
snugly. Before dressing is completed, the child should be submitted to a 
thorough examination for injuries received during delivery, congenital 
deformities, also as to the condition of the respiration, circulation, etc. 

l 



2 HYGIENE AND GENERAL CARE 

After dressing, the child should be placed in his crib and covered with 
blankets, and if the feet are cold, or the fingers and lips a little blue, he 
should be surrounded by hot-water bottles covered with flannel, and 
placed near, but not in contact with, the body. The crib should be placed 
in a quiet, darkened room. The young infant should not occupy the 
same bed as the mother, unless he greatly needs the warmth of her body, 
other means of artificial heat not being at hand. 

The cord should be kept dry and disturbed as little as possible until 
it falls off. Under ordinary circumstances the cord separates from the 
fourth to the seventh day, the average being the fifth day. The stump 
should then be covered with the sterilized talcum or bismuth powder, 
and a pad of sterile gauze about one-fourth of an inch thick and two 
inches square applied and secured in position by means of the abdominal 
band. The purpose of this is to prevent umbilical hernia. The pad 
should be continued for the first month. The use of stronger antiseptic 
dressings than those recommended is somewhat objectionable, since it 
preserves the cord too long and delays separation. The full bath should 
not be given until the cord has separated. 

The physician should always see to it that the infant cries enough to 
keep the lungs properly expanded. 

The question of food for the newly-born infant is considered in the 
chapter upon infant feeding. 

Bathing. — For the first few months the bath should be given at 98° 
F. The room should be warm, preferably there should be an open fire. 
The bath should be short and the body dried quickly, without too vigorous 
rubbing. The addition of salt to the bath is an advantage where the skin 
is unusually delicate or excoriations are present. One large handful 
should be used to a gallon of water. By the sixth month the temperature 
of the bath for healthy infants may be lowered to 95° F., and by the end 
of the first year to 90° F. Older children who are healthy should be 
sponged or douched for a moment at the close of the tepid bath with 
water at 65° or 70° F. During childhood the warm bath is preferably 
given at night. In the morning a cold sponge bath is desirable. This 
should be given in a warm room and while the child stands in a tub 
partly filled with warm water. This cold sponge should last but half a 
minute, and be followed by a brisk rubbing of the entire body. 

In some young infants and even older children there is no proper 
reaction after the bath, even when given at the temperatures mentioned ; 
children being pale, slightly blue about the lips and under the eyes. All 
tub bathing, and especially all cold bathing, should then be stopped, since 
a continuance can only be a drain upon the child's vitality. 

Clothing. — The clothing of infants should be light, warm, non-irri- 
tating to the skin, and loose enough to allow free motion of the extrem- 



THE CARE OF THE XEW LY-BORX CHILD 3 

ities ; nor should bands be pinned so tightly about the trunk as to embar- 
rass the movements either of the chest or of the abdomen. The chest 
should be covered with a woollen shirt, high in the neck and with long 
sleeves. All petticoats should be supported from the shoulders and not 
from waistbands. Canton flannel and stockinet are both superior as 
absorbents to the more commonly used linen diapers. Stockinet has the 
advantage of being very soft and pliable. Care should be taken that in 
infants the feet be kept warm. If the circulation is very poor, a bag of 
hot water should always be in the crib. Chilling of the surface is some- 
times responsible for attacks of colic. 

The abdominal band is usually worn during infancy. It cannot be 
considered in any sense a necessity after the first few months, except 
in cases of very thin infants whose supply of fat in the abdominal walls 
is an insufficient protection to the viscera. For the first few weeks a band 
of plain flannel is to be preferred; later, a knitted band with shoulder- 
straps. The fashion of low neck and short sleeves for infants and very 
young children has fortunately passed away — let us hope, not to return. 

During the summer the outer clothing should be light and the under 
clothing of the thinnest flannel or gauze. The changes in the tempera- 
ture of morning and evening may be met by extra wraps. The custom of 
allowing young children to go with legs bare has many enthusiastic advo- 
cates; while it may not be objectionable during the heat of summer, its 
advantages at any season are very questionable in a changeable climate 
like that of Xew York or the Atlantic coast. Many delicate children are 
certainly injured by such ill-advised attempts at hardening. 

The night clothing of infants should be similar to that worn during 
the day, but should be loose, the material being of the lightest flannel. 
The night clothing for older children should consist of a thin woollen 
shirt and a union suit with waist and trousers, and in some cases with 
feet, if there is a tendency to get outside the coverings. The common 
mistake is to overload all children, but especially infants, with covering 
at night. This is an explanation of much of the restless sleep which is 
seen, particularly in delicate children. 

Care of the Eyes. — During the first few days at the daily bath the 
eyes should be cleansed with a saturated solution of boric acid. They 
should be carefully protected from too strong light during early infancy. 
It is desirable that a child should always sleep in a darkened room. 

Care of the Mouth and Teeth. — The mouth of the newly-born infant 
should be gently cleansed at each morning bath with boiled water and 
a soft cloth. On the first appearance of thrush the mouth should be 
washed after every feeding with a solution of bicarbonate of soda or boric 
acid (ten grains to the ounce). It should be applied with a swab made 
by twisting a bit of cotton upon a wooden toothpick, and not by the 



4 HYGIENE AND GENERAL CARE 

nurse's finger. Harm is often done by the use of too much zeal in 
cleansing the mouth of a young infant. 

The primary teeth as well as those of the permanent set should receive 
daily attention. Too often they are neglected altogether. Dirty teeth 
are likely sooner or later to become carious; and carious teeth, besides 
being a cause of bad breath and pain, are a constant menace to the health 
of the child, since they are frequently the cause of severe infections. Such 
teeth should either be filled or removed. 

Care of the Skin. — The skin of a young infant is exceedingly delicate, 
and excoriations, intertrigo, and eczema are of very common occurrence. 
These conditions are much easier of prevention than of cure. The first 
essential in the care of the skin is cleanliness, and this must be secured 
without the use of strong soaps or too much rubbing. Napkins must be 
removed as soon as soiled or wet. Some bland absorbent powder, like 
starch, talcum, or the stearate of zinc, should be used in all the folds of 
the skin, in the neck, in the axillae, groins, and about the genitals, and 
in the folds of the thighs, particularly in very fat infants. If plain water 
produces an undue amount of irritation, the salt or bran bath should be 
employed. 

Care of the Genital Organs. — The female genitals need but little 
attention in young children, except as to cleanliness. This is more often 
neglected in older children than in infants. 

In males the prepuce should receive attention during the first few 
weeks of life. If the foreskin is long and the preputial orifice small, 
circumcision should be done. If it is not long, but is only adherent, 
these adhesions should be broken up, the parts thoroughly cleansed and 
the foreskin retracted dally until there is no disposition to a recurrence 
of the adhesions. These operations will be discussed more at length in 
a subsequent chapter. The only thing to be emphasized in the present 
connection is that the prepuce should receive proper attention in early 
infancy, since this can now be done with less pain and discomfort to the 
child, and at the same time better results are obtained. If this matter 
is neglected during infancy, it is apt to be overlooked until harm has 
been produced by local or reflex irritation which phimosis or adherent 
prepuce may have excited. 

Vaccination. — This, although considered elsewhere, should be men- 
tioned in this connection as among the things requiring the physician's 
attention during the first months of life. 

Training to Proper Control of Rectum and Bladder. — It is surprising 
to see what can be accomplished by intelligent efforts at training in these 
particulars. An infant can often be trained at three months to have its 
movements from the bowels when placed upon a small chamber. This 
not only saves a great amount of washing of napkins, but there is soon 



HYGIENE OF THE NERVOUS SYSTEM 5 

formed a habit of having the bowels move at a regular time or times each 
day. The infant must be put upon the chamber soon after his feeding. 
The importance of training young children to regular habits regarding 
evacuations from the bowels can hardly be overestimated. It should be 
impressed upon every mother and nurse by the physician, and especially 
the necessity of beginning training during infancy. Much of course will 
depend upon the food and the digestion ; but habit is a very large factor 
in the case. 

The training of the bladder is not quite so important, but the proper 
education of this organ adds much to the comfort of the child and the ease 
with which he is cared for. Before the end of the first year many intelli- 
gent children can be trained to indicate a desire to empty the bladder. 
Many mothers and nurses succeed in training children so well that by 
the tenth or eleventh month napkins are dispensed with during the day. 
On the other hand, it is very common to see children of two and even two 
and a half years still wearing napkins because of the lack of proper train- 
ing. Before he has reached the age of three years a healthy child will 
usually go from 10 p.m. until morning without emptying the bladder. 
The annoyance and discomfort .from the neglect of early training in this 
particular are very great. Night feeding is responsible for much of the 
difficulty experienced in training children to hold the water during the 
night. 

General Hygiene of the Nervous System. — Great injury is done to 
the nervous system of children by the influences with which they are 
surrounded during infancy, especially during the first year. The brain 
grows more during the first two years than in all the rest of life. Normal 
healthy development of the nervous centers demands quiet, rest, peaceful 
surroundings, and freedom from everything which causes excitement or 
undue stimulation. 

The steadily increasing frequency of functional nervous diseases 
among young children is one of the most powerful arguments for greater 
attention by physicians to the subject of hygiene of the nervous system 
during infancy. Most parents err through ignorance. Playing with 
young children, stimulating to laughter and exciting them by sights, 
sounds, or movements until they shriek with apparent delight, may be a 
source of amusement to fond parents and admiring spectators, but it is 
almost invariably an injury to the child. This is especially harmful when 
done in the evening. It is the plain duty of the physician to enlighten 
parents upon this point, and insist that the infant shall be kept quiet, 
and that all such playing and romping as has been referred to shall, 
during the first year at least, be absolutely prohibited. 

Sleep. — The sleep of the newly-born infant is profound for the first 
two or three days and under normal conditions almost continuous. In 



6 HYGIENE AND GENERAL CARE 

the case of prolonged or tedious labor, or where from any cause undue 
compression has been exerted upon the head, it may approach the con- 
dition of semi-coma for twenty-four or forty-eight hours. This may be 
so deep as to excite apprehensions of serious brain lesions. If, however, 
there are associated with it no convulsions and no rigidity, this early 
stupor usually passes away on the second or third day. 

The sleep of early infancy is quiet and peaceful, but not very deep 
after the first month. After the third year the heavy sleep of childhood 
is commonly seen. A healthy infant during the first few weeks sleeps 
from twenty to twenty-two hours out of the twenty-four, waking only 
from hunger, discomfort, or pain. During the first six months a healthy 
infant will usually sleep from sixteen to eighteen hours a day, the waking 
periods being only from half an hour to two hours long. At the age of 
one year most infants sleep from fourteen to fifteen hours, viz., from 
eleven to twelve hours at night, and two or three hours during the day, 
usually in two naps. When two years old usually thirteen to fourteen 
hours' sleep are taken; eleven or twelve hours at night and one or two 
hours during the day, generally in a single nap. At the age of four years 
children require from eleven to twelve hours' sleep. It is always desir- 
able, and in most cases with regularity it is possible, to keep up the daily 
nap until children are five years old. From six to ten years the amount 
of sleep required is ten or eleven hours, and from ten to sixteen years 
nine hours should be the minimum. 

Training in proper habits of sleep should be begun at birth. From 
the outset an infant should be accustomed to being put into his crib while 
awake and to go to sleep of his own accord. Eocking and all other habits 
of this sort are useless and may even be harmful. An infant should not 
be allowed to sleep on the breast of the nurse, nor with the nipple of the 
bottle in his mouth. Other devices for putting infants to sleep, such as 
allowing the child to suck a rubber nipple or anything else, are positively 
injurious. If such means of inducing sleep are resorted to the infant 
soon acquires the habit of not sleeping without them. We have known of 
one instance where the habit of rocking during sleep was continued until 
the child was two years old; the moment the rocking was stopped the 
infant would wake, and in consequence this practice was continued by 
the devoted but misguided parents. A quiet, darkened room, a warm 
and comfortable bed, an appetite satisfied, and dry napkins are all that 
are needed to induce sleep in a healthy child. 

The periods of sleep in young infants are usually from two to three 
hours long, with the exception of once or twice in the twenty-four hours, 
when a long sleep of five or six hours occurs. The purpose of training 
is to have the child take this long sleep at night. The habit of regular 
sleep is best established by wakening the infant regularly every three or 



EXERCISE 7 

four hours during the day for feeding, and allowing him to sleep as long 
as possible during the night. This training goes hand-in-hand with 
regular habits of feeding. Such habits are easily formed if the plan be 
systematically followed from the outset. 

By the fourth month all feeding between 10 p.m. and 6 a.m. should be 
discontinued. If this is done most infants can be trained by this time 
to sleep all night. If the room is lighted, and the child taken from the 
crib or rocked or fed as soon as he wakens at night, there is no such thing 
as the formation of good habits of sleep. Eegularity in sleep and feeding 
not only makes 'the care of young infants very much easier, but is of a 
good deal of importance for the health of the child. 

The causes of disturbed or irregular sleep in young infants are mainly 
two — hunger and indigestion. In nursing infants it is usually the for- 
mer ; in those artificially fed usually the latter. Sleeplessness from hun- 
ger is often seen in children who are nursed thirty or forty minutes and 
then fall asleep, but wake in fifteen or twenty minutes crying and fretful. 
After being quieted they may fall asleep again for half an hour, but 
wake at short intervals. The peaceful sleep of two or three hours which 
should follow a proper feeding is never seen. With this restlessness from 
indigestion other signs are usually present, stationary weight, etc. The 
disturbed sleep due to overfeeding shows itself by much the same symp- 
toms, except that the first sleep after the meal is usually longer. 

Exercise. — This is no less important in infancy than in later child- 
hood. An infant gets his exercise in the lusty cry which follows the cool 
sponge of the bath, in kicking his legs about, waving his arms, etc. By 
these means pulmonary expansion and muscular development are in- 
creased and the general nutrition promoted. An infant's clothing should 
be such as not to interfere with his exercise. Confinement of the legs 
should not be permitted. In hospital practice we have often had a chance 
to observe the bad results which follow when very young infants are 
allowed to lie in the cribs nearly all the time. Little by little the vital 
processes flag, the cry becomes feeble, the weight is first stationary, then 
there is a steady loss. The appetite fails so that food is at first taken 
without relish, then at times altogether refused; later, vomiting ensues 
and other symptoms of indigestion. This, in many cases, is the beginning 
of a steady downward course which goes on until a condition of hopeless 
marasmus is reached. Such infants must be taken up every few hours 
and carried about the wards; the position should be frequently changed, 
and general friction of the entire body employed at least twice a day. 
Every means must be made use of to stimulate the vital activity. The 
value of systematic attention to these matters cannot be overestimated in 
hospitals for infants. Infants who are old enough to creep or stand 
usually take sufficient exercise unless they are restrained. At this age 



8 HYGIENE AND GENERAL CARE 

they should be allowed to do what they are eager to do. Every facility 
should be afforded for using their muscles. Exercise may be encouraged 
by placing upon the floor in a warm room a mattress or a thick "com- 
fortable/' and allowing the infant to roll and tumble upon it at will. A 
large bed may answer the same purpose. 

In older children every form of out-of-door exercise should be encour- 
aged — ball, tennis, and all running games, horseback riding, the bicycle, 
tricycle, swimming, coasting, and skating. Up to the eleventh year no 
difference need be made in the exercise of the two sexes. Companionship 
is a necessity. Children brought up alone are at a great' disadvantage in 
this respect, and are not likely to get as much exercise as they require. 
The amount of exercise allowed delicate children should be regulated 
with some degree of care. It may be carried to the point of moderate 
muscular fatigue, but never to muscular exhaustion. The latter is par- 
ticularly likely to be the case in competitive games. 

Exercise should have reference to the symmetrical development of the 
whole body. In prescribing it the specific needs of the individual child 
should be considered. By carefully regulated exercises very much may 
be done to check such deformities as round shoulders and slight lateral 
curvature of the spine, and also to develop narrow chests and feeble 
thoracic muscles. For purposes like these, gymnastics are exceedingly 
valuable to supplement out-of-door exercise, but they can never take their 
place. 

There are two important points with reference to exercise indoors. 
First, the playroom should be cool — about 60° F. Secondly, during all 
active exercise the clothing should be loose and light, so as to allow the 
freest possible motion of the body. 

Airing. — In summer there can be no possible objection to a young 
infant being allowed out of doors at the end of the first week. He should 
be kept in the open air as much as possible during the day. In the fall 
and spring this should not be permitted until the child is at least a month 
old, and then only when the out-of-door temperature is above 60° F. 
During his outing the head should be protected from the wind and the 
eyes from the sun. The duration of the outing at first should be only 
fifteen or twenty minutes, the time being gradually lengthened to two or 
three hours. The child should be gradually accustomed to changes of 
temperature in the room by opening wide the windows for a few minutes 
each day even before he is taken out of doors, the child being dressed 
meanwhile as for an outing. In the case of children born late in the fall 
or in the winter this means of giving fresh air may be advantageously 
begun at one month and followed throughout the first winter. It is only 
necessary in all such cases that the changes be made very gradually both 
as to the length of the airing and as to the temperature. The great 



NURSERY 9 

advantage of this plan over that more commonly followed of keeping 
3'Oimg infants closely housed for the first six months in case they are 
born in the fall or early winter, we can positively affirm from quite a 
wide observation of both methods. It is a matter of very serious impor- 
tance that every infant be furnished an abundance of pure fresh air in 
winter as well as in summer. When the plan above outlined is carefully 
and judiciously followed, the tendency to catarrhal affections instead of 
being increased is thereby greatly lessened. 

When four or five months old, there is no reason why a healthy child 
should not go out of doors on pleasant days if the temperature is not 
below 20° F. While there is a prejudice on the part of many mothers 
and some physicians against a child's sleeping out of doors in cold 
weather, it is a practice which we have always urged upon mothers, and 
have never seen followed by any but the most beneficial results. The 
days of all others when infants and very young children should not be 
out of doors are when there are high winds, especially those from the 
northeast, an atmosphere of melting snow, and during severe storms. 
Delicate infants must of course be more carefully guarded during the 
cold season. With most of these the plan of house-airing is all that 
should be attempted. 

Nursery. — This should be the sunniest and best-ventilated room in 
the house. It is the physician's duty to see that proper attention is paid 
to the hygiene of the room in which the child spends at least four-fifths 
of his time during the first year, and two-thirds of his time during the 
first two or three years of life. Sunlight is absolutely indispensable. 
Sunny rooms always contain less organic matter and less humidity, and 
hence a room upon the north side of the house should always be avoided ; 
preferably one in the second story should be chosen. Nothing which can 
in any way contaminate the air of the room should be allowed. There 
should be no washing and drying of clothes or of napkins. No food 
should be allowed to stand about the room. Gas should not be allowed 
to burn at night; a small wax night-light furnishes all that is needed 
in the nursery. If possible the heat should be from an open fire; the 
next best thing is the Franklin heater. Nothing in the room is worse 
than steam heat from a radiator unless it be a gas stove, which under no 
circumstances should be allowed, except possibly for a few minutes each 
morning during the bath. 

The temperature of the room during the day should not be over 70° 
F. It is important that every nursery should have a thermometer, and 
that this and not the sensations of the nurse should be the guide. It is 
almost invariably true that the nursery is overheated. Often no other 
explanation can be found for chronic indigestion and falling weight 
excepting a nursery whose habitual temperature ranges from 75° to 80° 



10 HYGIENE AND GENERAL CARE 

F. At night for the first few weeks the temperature should not be allowed 
to fall below 65° F. After two months the night temperature may fall to 
G0° or even 50° F. 

Free ventilation without draughts is an absolute necessity. This is 
best accomplished by ventilators in the windows, of which there are many 
excellent devices sold in the shops. While the child is absent from the 
room the windows should be widely opened and free airing of the nursery 
accomplished. The room should always be thoroughly aired at night 
before the child is put to bed. After the first year the window may be 
open, unless the outside temperature is as low as 20° F. If the window 
is open the door of the nursery should be closed, that currents of air may 
be avoided. The ventilation by means of an open fire is the most efficient. 

The furniture of the nursery should be as simple as possible, heavy 
hangings should be positively forbidden, and upholstered furniture used 
only to a small extent. Floors covered by large rugs are much more 
cleanly than carpets, and hence are to be preferred. 

The child, whenever it is possible, should have a separate bed; and 
so should the newly-born infant, in order to prevent the danger of over- 
lying by the mother, which is seen as an occasional cause of death, and 
also to avoid the danger of too frequent night nursing, which is injurious 
alike to mother and child. Separate beds for older children will prevent 
the spread of many forms of infection. The crib for infants should 
be one which does not rock, in order that this unnecessary and vicious 
practice may not be carried on. The mattress should be of hair and 
quite firm. The pillow should be small ; in the summer, hair pillows are 
an advantage but not a necessity. The position of the child during sleep 
should be changed from time to time from one side to the other and then 
to the back. Attention to all these details should not be beneath the 
physician's notice, since the violation of these plain rules of hygiene is 
at the bottom of many of the milder disorders and even of some of the 
more serious diseases seen in infancy. 

The Nurse, — The nurse of a young child should be healthy, young 
or in middle life, free from tuberculous or syphilitic taint, from catarrhal 
affections of the nose and throat, and not of a nervous or excitable tem- 
perament. She should be neat in habit, of quiet disposition, and, most 
of all, she should be a person of intelligence. 

The Amount of Air Space Required by Infants. — The nursery should 
always be as large a room as possible. One of the reasons why young 
infants do so badly in institutions is because of overcrowding. In a 
well-ventilated ward there should be allowed to each infant at least 1,000 
cubic feet. Children over two years old are not so sensitive to their 
surroundings, and may thrive in wards where only 700 or 800 cubic feet 
are allowed to each child. 



PREMATURE AND DELICATE INFANTS 11 



THE CARE OF PREMATURE AND DELICATE INFANTS 

Infants born before term, and some exceedingly delicate ones who 
are born at full term, require very special and particular care. The 
vitality is so feeble in these children that if they are handled in the 
ordinary way they survive at most but a few weeks. The symptom which 
indicates that such special care is necessary is most of all the weight of 
the child. Either congenital feebleness or prematurity may be assumed 
in most of the children weighing less than five pounds ; also if the length 
of the body is less than nineteen inches. In these children all the organs 
are likely to be imperfectly developed and they are not ready for their 
work. Especially is this true of the lungs and of the organs of digestion. 

The clinical picture presented by these cases is quite characteristic. 
The body is limp ; the skin very soft and delicate and almost transparent ; 
the cry, a low feeble whine not unlike the mew of a kitten ; the respiratory 
movements, extremely irregular, sometimes scarcely perceptible for several 
seconds ; the movements of the extremities infrequent and never vigorous. 
The general appearance is one of torpor. The muscles of the mouth and 
cheek and tongue may lack the requisite force for sucking, so that this is 
practically impossible, and even deglutition is slow, difficult, and pro- 
longed. It is difficult to maintain the normal body temperature ; unless 
closely watched this may fall far below the normal, and may rise quite 
as much above it with the use of too much artificial heat. We once saw 
a fluctuation of 13° F. occur in a few hours from such causes. All the 
symptoms mentioned vary much according to the degree of prematurity. 

In the management of these cases there are three problems to be 
solved : the first to maintain the animal heat, the second to nourish the 
infant, the third to prevent infection. Difficult as it always is to rear a 
premature infant, these difficulties are much increased in cases where 
proper means are not adopted immediately after birth. The loss which 
these children sustain during the first few days is in very many cases so 
great that subsequent measures, however well carried out, are futile. The 
heat-producing power is so feeble that the body temperature quickly falls 
below normal unless artificial heat is constantly used. The effect of cold 
upon these delicate infants is very serious, and not only growth but even 
life depends upon maintaining the body temperature steadily and uni- 
formly. Their extreme susceptibility is something which it is difficult 
for one to appreciate who has not had experience in these cases. 

One of the simplest means of maintaining the temperature is to oil 
the skin and then roll the entire body, including extremities, in absorbent 
cotton or lamb's wool : even the neck and cranium may be covered, leaving 
only the face exposed. The usual diaper may be replaced by a pad of 



12 HYGIENE AND GENERAL CARE 

gauze and absorbent cotton. The body is then wrapped in blankets, 
placed in a clothes-basket or bassinet with protected sides, and surrounded 
by bottles or bags containing hot water. A blanket or sheet should par- 
tially cover the top of the basket, forming a sort of hood to protect the 
eyes from light and the face and head from draughts. In using hot- 
water bags, some caution must be exercised or too much heat may be 
secured. We have seen the temperature of an infant raised six or seven 
degrees from this cause. The temperature of the child should at first be 
taken every few hours to make sure that a proper amount of external 
heat is supplied. 

A more efficient means of furnishing artificial heat is by the electric 
pad. These small heaters may be attached like a drop-light to any 
electric fixture. A convenient size is ten by fifteen inches. The pad, 
which can be obtained of any electric supply company, is placed beneath 
two or three thicknesses of blanket, upon which the infant lies in its 
basket. Since the pads occasionally get out of order they must be used 
with some caution, as they have been known to burn the bedclothes and 
even the baby. 

With such means as those described it is possible to maintain the body 
temperature at normal even in a room kept at the ordinary temperature. 
It is preferable to have a warmer room; 80° or even 85° F. is desirable 
for feeble infants. Adequate ventilation, however, is indispensable. 
With intelligent care excellent results can, however, often be obtained 
with no other means for maintaining heat than the padded basket and 
hot-water bottles; but the other accessories make the problem an easier 
one. 

Premature infants should be fed without being removed from the 
basket, until they are strong enough to take the breast. The position 
should be frequently changed and some freedom of movement of the 
limbs permitted, but the infants should be handled as little as possible. 
The body should be oiled and fresh cotton applied every other day. The 
rectal temperature at first should be taken several times a day in order 
to be sure that sufficient artificial heat is being supplied, but not too 
much. The latter condition is one that often obtains. So long as the 
rectal temperature varies only between 98° and 100° F. one should be 
satisfied. 

Incubators. — Personally, we have not found the usual small incubator 
a very satisfactory means of caring for the premature infant. The diffi- 
culties in successful operation are many and the dangers consequent upon 
the mode of ventilation are considerable. Except by persons experienced, 
their use is not to be advised. In hospitals with specially trained nurses 
they may give excellent results, but in the average home the simpler 
measures above described are much safer and quite efficient. 



PREMATURE AND DELICATE INFANTS 13 

Every institution receiving and caring for premature infants should 
have a specially equipped room for that purpose. It should be of suffi- 
cient size to accommodate several patients. We have had such a room 
constructed in the Babies' Hospital which seems to fulfill all the require- 
ments. The room has a floor space of thirteen by sixteen feet with ceiling 
eleven feet high. This is arranged for five infants, which gives each 
child 450 cubic feet of air. The cribs are separated by glass plates, which 
project three feet from the side wall and are four feet in height, form- 
ing an alcove for each infant. The purpose of this is to diminish the 
chances of bed-to-bed infection. The room has double partition walls 
and double windows. The temperature is controlled by a thermostat 
regulator and is maintained at about 90° F. The room is provided with 
a special ventilating apparatus by means of which the entire air of the 
room can be changed in a few minutes. This is done several times a day. 
Such a room possesses all the advantages of the small incubator without 
any of its drawbacks. The infants are clothed in a single loose garment 
of absorbent cotton and cheese-cloth and lightly covered. In this room 
the normal body temperature is easily maintained. For wet-nursing, 
bathing, and changing of napkins, the children are removed to an ante- 
room which is kept at a temperature of about 75° F. When the bottle 
is given they are fed in their cribs. After reaching the weight of about 
five pounds they are removed to the anteroom for a few days, after which 
they are placed in the ward or sent home. 

Feeding. — The feeding of the premature infant is not less important 
than the maintenance of heat and proper ventilation. Infants at eight 
months and those weighing five pounds or thereabouts can usually be 
made to take the breast after the first few days. Few below this age or 
weight will do so. Some will suck from a bottle, but the majority must 
be fed by other means. A medicine dropper may be used, or the Breck 
feeder ; the smallest and feeblest, however, must be fed by gavage, using a 
funnel and small rubber catheter. The food should be slowly given; if 
rapidly, some is liable to be regurgitated, and this may produce attacks 
of asphyxia or even an aspiration pneumonia. The quantity of food and 
frequency of feeding will depend upon the size and age of the child. A 
seven months' baby weighing three and a half pounds should have, for the 
first twenty-four hours, only water, one to three teaspoonfuls every hour. 
Then regular food every three hours beginning with half an ounce, in- 
creased to one ounce in a few days and gradually to one and a half or two 
ounces at the end of about three weeks. 

Artificial feeding is seldom very successful with premature infants. 
With some of the larger and more vigorous, cow's milk modified accord- 
ing to the directions given in the chapters on Infant Feeding gives good 
results. We once succeeded with a child of three pounds two ounces. For 



14 



HYGIENE AND GENERAL CARE 



most of them under four and a half pounds, breast-milk is essential. If 
the child is born near term, the mother may be able to nurse it. Occa- 
sionally this may be done at eight months, but seldom earlier, so that the 
milk of some other woman must usually be depended upon. 

As the premature baby requires only from six to eight ounces of 
breast-milk a day for the first few weeks, this may be secured from some 
other nursing woman ; a friend might be willing to furnish it or it could 
be purchased from any healthy woman who has an abundant supply. It 
is sufficient if it is drawn fresh twice a day, the utmost precautions, of 
course, being taken to secure cleanliness. At first equal parts of breast- 
milk and a four- or five-per-cent solution of milk sugar may be given; 
the degree of dilution being gradually lessened until pure milk is taken. 
Eight feedings a day are usually necessary, the amount at one feeding 
may be from two drams to one ounce depending upon the size, age, and 
digestive powers of the infant. It is not important that the baby of the 
woman furnishing the milk should be of the same age as the foster infant. 
The milk of any woman whose baby is between one and eight months old 
will answer. We have successfully fed premature infants with breast- 
milk from women whose children were older than this. Another plan is to 
secure a wet-nurse and permit her to bring her own baby into the house. 
She expresses for the premature infant the required amount of milk 
three or four times a day, and the rest of the time nurses her own child. 
In this way her flow of milk is maintained; if the breasts are pumped 
exclusively the supply rapidly diminishes. The secretion of the milk in 
the mother may be promoted by her suckling the wet-nurse's baby or 
some other vigorous infant. The above are temporary expedients and in 
most instances need not be continued more than two or three weeks, at 
the end of which time the mother may be able to nurse her own child. 

The results with premature babies will depend very much upon how 
soon after birth they receive proper care. Immediately after birth meas- 
ures should be taken to secure the best care and provide adequately for 











Voorhees saved 




Tarnier saved 


Tarnier saved 


Voorhees 


excluding cases 


Age. 


without incu- 


with incubators. 


saved with 


dying a few 




bators. 




incubators. 


hours after birth. 


Born at 6 months 


o.o% 


16.0% 






" " 6£ " 


29.5% 


36.6% 


22.0% 


66.0% 




39.0% 


49.8% 


41.0% 


71.0% 


" " 7h " 


54.0% 


77.0% 


75.0% 


89.0% 




78.0% 


88.8% 


70.0% 


91.0% 


' : "8| " 


88.0% 


96.0% 







maintaining the body heat. If an incubator is to be used it should be 
in readiness, so that the child can be put into it as soon as he is breathing 
properly. The age and vigor of the infant are of the greatest impor- 



WEIGHT 15 

tance in estimating the chances of survival. The table on the preceding 
page gives Tarnier's statistics, showing the percentage of premature in- 
fants saved during a period of five years without the incubator, and dur- 
ing the succeeding five years with the incubator ; also the percentage saved 
at the Sloane Hospital for Women (New York), as published by Voorhees. 
Eesults will improve with the experience of the physician in the feed- 
ing and care of these very sensitive patients. Much is yet to be learned 
about them. 



CHAPTER II 
GROWTH AND DEVELOPMENT OF THE BODY 

Observations upon growth and development are of the utmost impor- 
tance during infancy and childhood. Only by this means are very many 
diseases detected in their incipiency. Early recognition carries with it 
in most cases the possibility of checking such pathological processes as, 
if allowed to go on, may affect the health not only in infancy but even 
throughout life. 

By familiarity with what is normal, detection of the abnormal soon 
becomes easy. Investigation in regard to these subjects should be made 
a part of the physical examination of every child. 

WEIGHT 

The weight of the infant is the best means we have to measure his 
nutrition. It is as valuable a guide to the physician in infant feeding as 
is the temperature in a case of continued fever. Although the weight is 
not to be taken as the only guide to the child's condition, it is of such 
importance that Ave cannot afford to dispense with it during the first two 
years. It is of great advantage to keep up regular observations during 
childhood. 

Weekly weighings should be made for the first six months, bi-weekly 
for the rest of the first year, and monthly during the second year. Del- 
icate children should be weighed even more frequently. Balance scales 
only should be used. The spring scales are not reliable. 

Weight at Birth. — The following figures are taken consecutively in 
nearly equal proportion from the records of the Nursery and Child's Hos- 
pital, the Sloane Hospital, and the New York Infant Asylum, and 
include only full-term children : 

Average weight of 568 females 7. 16 lbs. (3,260 grams). 

590 males 7.55 " (3,400 " ). 



u 



1,158 infants 7.35 " (3,330 " ). 



16 



GROWTH AND DEVELOPMENT 



Weight Curve during the First Few Weeks. — The accompanying 
chart represents the variations in weight for the first twenty days. These 
observations were made upon one hundred healthy, nursing infants, fifty 
males and fifty females, at the Nursery and Child's Hospital. The 
children were weighed daily during the period of observation. The 
average weight at birth was 7.1 pounds. The curve shows a very 
marked loss of weight on the first day and a slight loss on the second 
day, the lowest point being touched at the beginning of the third day; 
but from this time there was a steady gain. The average initial loss in 



DAILY WEIGHT CHART. 
Name...... Date of Birth, -.189 


Gms. 


Lbs. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


16 


17 


18 


19 


20 


4420 
4310 
4200 
4080 
3970 
3850 
3740 
3630 
3510 
3400 
3290 
3180 
3060 
2940 
2830 
2720 
2610 
2490 
2380 


9% 
9 l A 

9 

8 
1 X A 

7 
6^ 

6 

5M 



































































































































































































































































































































































































































































































































































































































































































































































































































Fig. 1. — Weight Curve of the First Twenty Days. 



these cases was ten ounces, being in each sex exactly eleven per cent of 
the body weight. In eight hundred and thirty-five cases, including 
those above mentioned, the average loss was nine and a half ounces. 
The loss of the first days is chiefly due to the discharge of the meconium 
and urine, but is in part from the excess of tissue waste over the nutri- 
ment derived from the breasts. After the third day, coincident with 
an abundant secretion of milk, there is a steady, daily increase in weight. 
If the milk is very scanty or is wanting altogether, the loss in weight 
continues. 

The birth-weight of nursing children who thrive normally is regained 
on the average on the tenth day. The most frequent deviation from the 
normal curve consists in a continued loss or stationary weight after the 



WEIGHT 



17 



third day. This may be due to acute illness, such as bronchitis, diar- 
rhea, pyemia, or hemorrhage, but in the majority of cases there is a 
disturbance of nutrition from improper or insufficient food. 

The weight curve of infants who are artificially fed, even though 
they are strong and vigorous and the feeding properly done, rarely fol- 
lows for the first month the same line as that of nursing infants. We 



Name 
































WEIGHT 

Date 


CHART 

nfRirt.h 191 










m 

2 
O 


CD 

-1 


WEEK OF AGE 


1 12 24 36 48 


10390 
10430 
9980 
9530 
9070 
8620 
8160 
7710 
7260 
6800 
6350 
5900 
5440 
4990 
4540 
4080 
3630 
3180 
2720 
2270 


24 
23 
22 
21 
20 
19 
18 
17 
16 
15 
14 
13 
12 
II 
10 
9 
8 
7 
6 
5 


























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































*> 




































































































^ 














































































































































































































































































































\y 




































































































S 




































































































s 


' 




































































































/ 






































































































s 






































































































/ 






































































































/ 






































































































/ 






































































































/ 






































































































/ 






































































































/ 






































































































/ 






































































































/ 


































































































£ 


V 


/ 

























































































































































































































































































































































































































































































































































































































































































































































































































































Fig. 2. — Weight Chart. 



usually see an initial loss which is about the same as in nursing infants, 
then a period of nearly stationary weight lasting from one to two weeks. 

Excessive loss in weight during the first few days, from any cause 
whatsoever, seriously handicaps an infant during the first weeks of its 
life. The great importance of this has not been sufficiently appre- 
ciated. 

Weight Curve of the First Year. — The curve of the accompanying 
chart is made up from complete weight charts of about two hundred 
healthy nursing infants who were thriving and weighed every week, and 
the incomplete charts of about five hundred other infants. There are 
represented in round numbers about thirty thousand observations on chil- 
dren under one year. The period of most rapid increase is during the 



18 GROWTH AND DEVELOPMENT 

first three months. It is slowest from the sixth to the ninth month. This 
curve is not to be regarded as a normal line, like the normal line of the 
temperature chart, but as an average line. An infant who is at birth a 
pound above the average may keep this distance above the line for the 
whole year; another, weighing one pound less than the average, may be 
as far below it. Girls throughout the year are on the average half a 
pound lighter than boys. No single child exactly follows the line all 
the way, but it is surprising how close to it a very large number of the 
cases come. 

In artificially-fed infants who are healthy and are properly fed, the 
curve does not differ essentially from that of breast-fed infants, except 
in the slower gain of the first month, although this difference is usually 
made up before the sixth month is reached. 

At the end of the first year the average child weighs nearly three 
times as much as at birth. Perfect health during the first year is seen 
only in children who are gaining steadily in weight. A child may not 
always gain rapidly, but he should gain steadily, and if he does not, some- 
thing is wrong. All the conditions surrounding the infant should be 
investigated, but especially the food. One should not be satisfied unless 
the average weekly gain during the first six months is at least four 
ounces. In the second six months it may be slightly less. As a rule, a 
child who gains regularly in weight is thriving ; an exception must, how- 
ever, be made in the case of some infants who are fed chiefly upon carbo- 
hydrate foods. 

Weight from the Second to the Fifth Year. — Comparatively few ob- 
servations have been published upon the weight during this period. From 
nearly two thousand personal observations, chiefly from private practice, 
it appears that the normal gain of a healthy child is about six pounds 
during the second year, about five during the third year, and about four 
pounds during the fourth year; the actual weights are given in the 
large table on page 20. During this period the gain is rarely uniform 
after the first year. With most children it is slowest or the weight is 
stationary in the summer months, while the most rapid increase is 
usually seen in autumn. Throughout this period girls gain in about 
the same ratio as boys, but remain on the average nearly one pound 
lighter. During almost every illness, no matter of what character, 
the gain in weight ceases, and usually there is a loss, the rapidity and 
extent of which are somewhat proportionate to the severity of the attack; 
but it is always much more rapid in diseases of the digestive tract than 
in any other form of illness. 

Weight of Older Children. — The weights given in the table of children 
from five to fourteen years are from Bowditch. Observations were made 
upon children of American parentage in the public schools of Boston — 



HEIGHT 



10 



upon 4,327 boys and 3,681 girls. 1 It is to be remembered that these 
weights include the ordinary clothing, while those below five years fire 
without clothing.'- Our own observations upon children in private prac- 
tice show that the average weight for the fifth and sixth years is one 
pound greater and from the seventh to the tenth year from two to 
three pounds greater than the averages of the public school children 
given by Bowditch. 

The slowest gain is from the fifth to the eighth year, when it is about 
four pounds a year. From the eighth to the eleventh year it rises to 
about six pounds a year. Up to the eleventh year the two sexes gain 
in about the same ratio. From the eleventh to the thirteenth year the 
girls gain much more rapidly, passing the boys for the first time and 
maintaining this lead until the fifteenth year, when again the boys 
pass them. 

HEIGHT 

The figures showing the height at different ages are given in the table 
on page 20. The measurements of infants at birth, given on page 21, are 
taken in about equal numbers from the records of the New York Infant 
Asylum and the Sloane Hospital for Women. They were made upon 
full-term infants. 



1 W. T. Porter has published (1894) observations made upon 14,744 children of 
American parentage in the public schools of St. Louis. His figures show quite a 
variation from those of Bowditch, and are as follows: 



Age. 


boys' weight. 


girls' 


WEIGHT. 


Kilos. 


Pounds. 


Kilos. 


Pounds. 


6 years 


19.66 
21.67 
23.91 
26.08 
28.49 
31.26 
33.45 
35.96 
40.34 
47.25 
52.10 


43.2 
47.7 
52.6 
57.4 
62.7 
68.8 
73.6 
79.1 
88.7 
103.9 
114.6 


18.76 

20.82 
22.71 
25.07 
27.43 
29.93 
33.17 
38.29 
43.12 
46.90 
50.06 


41.3 


7 " 


45.8 


8 " 

9 " 


50.0 
55.1 


10 " 

11 " 

12 " 

13 " 


60.3 

65.8 
73.0 

84.2 


14 " 


94.9 


15 " 


103.2 


16 " 


110.1 







2 The average weight of the ordinary house clothing of school children, accord- 
ing to Bowditch, is at five years, 2.8 pounds for both sexes; at seten years, 3.5 for 
both sexes; at ten years, 5.7 pounds for boys and 4.5 pounds for girls; at thirteen 
years, 7.4 pounds for boys and 5.6 pounds for girls; at sixteen yours. 9.7 pounds 
for boys and 8.1 pounds for girls. This must be deducted to obtain net weights. 



20 



GROWTH AND DEVELOPMENT 



Table showing Weight, Height, and Circumference of the Head and Chest from Birth to 

the Sixteenth Year. 1 



Age. 


Sex. 


Weight, 


Height. 


Chest. 


Head. 


Pounds. 


Kilos. 


Inches. 


Cm. 


Inches. 


Cm. 


Inches. 


Cm. 


Birth 2 


Boys. 

Girls. 


7.55 

7.16 


3.43 

3.26 


30.6 

20.5 


53.5 

52.2 


13.4 

13.0 


34.3 

33.2 


13.9 

13.5 


35.5 

34.5 


6 months 2 . . . 


Boys. 

Girls. 


16.0 

15.5 


7.36 

7.03 


354 

25.0 


64.8 

63.6 


16.5 

16.1 


43.0 

41.0 


17.0 

16.6 


43.5 

42.2 


12 months 2 . . 


Boys. 

Girls. 


31.0 

20.5 


9.54 

9.31 


39.0 

28.7 


73.8 
73.2 


18.0 

17.4 


45.9 

44.4 


18.0 

17.6 


45.9 

44.6 


18 months 2 . . 


Boys. 

Girls. 


34.0 

23.5 


10.90 

10.68 


30.0 

29.7 


76.3 

75.6 


18.5 

18.0 


47.1 

45.9 


18.5 

18.0 


47.1 

45.9 


2 years 2 . . . . 


Boys. 

Girls. 


37.0 

26.0 


13.37 

11.81 


33.5 

32.5 


83.8 

82.8 


19.0 

18.5 


48.4 

47.0 


18.9 

18.6 


48.3 
47.2 


3 years 2 . . . . 


Boys. 

Girls. 


33.0 

31.0 


14.55 

14.00 


35.0 

35.0 


89.1 

89.1 


30.1 

19.8 


51.1 

50.5 


19.3 

19.0 


49.0 

48.4 


4 years 2 . . . . 


Boys. 

Girls. 


36.0 

35.0 


16.36 

15.90 


38.0 

38.0 


96.7 

96.7 


30.7 

20.7 


53.8 
52.2 


19.7 

19.$ 


50.3 

49.6 


5 years 


Boys. 

Girls. 


41.3 

39.8 


18.71 

18.06 


41.7 

41.4 


106.0 

105.3 


31.5 

21.0 


54.8 

53.5 


30.5 

20.? 


53.3 

51.3 


6 years 


Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 


45.1 

43.8 

49.5 

48.0 

54.5 

52.9 

60.0 

57.5 

66.6 

64.1 


30.48 

19.87 

33.44 

21.78 

34.70 

24.01 

36.58 

26.10 

30.33 

29.07 


44.1 

43.6 

46.3 

45.9 

48.3 
48.0 

50.1 

49.6 

53.3 

51.8 


113.0 

110.9 

117.4 

116.7 

133.3 

122.1 

137.3 

126.0 

133.6 

131.5 


33.3 

22.8 

33.7 

23.3 

34.4 

23.8 

35.1 

24.5 

35.8 
24.7 


59.1 

58.3 

60.6 

59.5 

63.3 

60.8 

63.9 

62.5 

65.6 

63.0 










7 years 










8 years 










9 years 










10 years 


31.0 

20.7 


53.5 

52.8 


11 years 


Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 


73.4 

70.3 

79.8 

81.4 

88.3 
91.3 


33.83 

31.87 

36.31 

36.90 

40.04 

41.36 


54.0 

53.8 

55.8 
57.1 

58.3 

58.7 


137.3 

136.6 

141.7 

145.2 

147.7 

149.2 


36.4 

25.8 

37.0 

26.8 

37.7 

28.0 


67.3 

65.8 

68.8 
68.3 

70.6 

71.3 










12 years .... 










13 years .... 










14 years .... 


Boys. 

Girls. 


99.3 

100.3 


45.03 

45.50 


61.0 

60.3 


155.1 

153.2 


38.8 
29.2 


73.3 

74.1 










15 years .... 


Boys. 

Girls. 


110.8 

108.4 


50.36 

49.17 


63.0 

61.4 


159.9 

159.9 


30.0 

30.3 


76.6 

76.8 


31.8 

21.5 


55.5 

54.8 


16 years 


Boys. 

Girls. 


133.7 

113.0 


56.09 

51.24 


65.6 

61.7 


166.5 

156.7 


31.3 

30.8 


79.3 

78.8 

















1 The observations of Boas 
years old show that first born 
and weight. 

2 These weights are without clothes; after five years clothes are included. 



(Science, April 12, 1895) upon 4,319 children over six 
exceed children born at a later period both in height 



GROWTH OF EXTREMITIES AS COMPARED WITH TRUNK 21 

Average length of 231 male infants born at term. . 20.61 inches (52.5 cm.): 
"211 female " " " " 20.47 " (52.2 " ); 

"442 infants 20.54 " (52.35"). 

The most rapid gain in length is in the first year. During this period 
the child grows on an average a little over eight inches (21 cm.). This 
gain is usually, but not always, proportionate to the increase in weight. 
During the second year the average increase is three and a half inches (9 
cm.). From this time on the rate of increase is quite uniform in both 
sexes until the eleventh year, it being between two and three inches a 
year. 

After the eleventh year in girls and the twelfth in boys the growth is 
much more rapid. In height the girls exceed the boys at the twelfth 
and thirteenth years for the only time in their growth. 

In the figures given in the preceding table those of five years and over 
are taken from Bowditch, the observations being made upohvthe same 
children as those whose weights were taken. The observations from six 
months to four years inclusive are from original sources, and are drawn 
from about eight hundred cases. The height much more than the weight 
of children is modified by hereditary influences. , 

Eachitic children during infancy and early childhood are, as a rule, 
shorter than others. We have frequently measured such children during 
the third year who were six inches below the average for that age. The 
effect of malnutrition upon the length of the body is much less than 
upon the weight. 



GROWTH OF THE EXTREMITIES AS COMPARED WITH THE TRUNK 

At birth the trunk is relatively long and the extremities short. The 
middle of the body at birth, according to one hundred observations on 
normal infants made for us by Wilbur Ward at the Sloane Hospital, is 
three-quarters of an inch (2 cm.) below the center of the umbilicus'. 
Subsequently the growth of the extremities is much more rapid than that 
of the trunk. Thus we have found at birth the length of the lower ex- 
tremities (measuring from the anterior superior spine of the ilium to the x S 
sole of the foot) to be forty-three per cent of the length of the body; at 
five years, fifty-four per cent, and at sixteen years, sixty^ef cent. The 
above figures are from one hundred and fifty observations, which, al- 
though not numerous enough for exact percentages, are still sufficient to 
give a very good idea of the general relation of the length of the extrem- 
ities to that of the body as a whole. These facts are of some assistance 
in the diagnosis of diseases attended by abnormalities of growth, such 
as rickets, cretinism, and chondrodystrophy. 



$..** 



22 GROWTH AND DEVELOPMENT 



THE HEAD 



Circumference, — The average circumference of the head at birth in 
four hundred and forty-six full-term infants observed at the Sloane 
Hospital and New York Infant Asylum was as follows : 

Average circumference of the head, 231 males 13.90 inches (35.5 cm.); 

215 females 13.52 " (34.5 " ); 

Total 446 infants 13.71 " (35.0 " ). 

The occipitofrontal measurement was the one taken. 

The growth of the head is most rapid during the first year, the in- 
crease being about four inches (10 cm.). It is about half an inch a 
month during the early months, and a fourth of an inch a month dur- 
ing the later months of the first year. During the second year the 
increase is about one inch (2.5 cm.). From the second to the fifth year 
the growth is slower, being only about one and a half inches (4 cm.) for 
the three years. After the fifth year the increase in the circumference 
of the head is very slow (see table). 

Closure of the Sutures. — The main sutures of the cranium are not 
commonly ossified before the end of the sixth month, and very frequently 
some mobility may be detected at the end of the ninth month. Distinct 
separation of the cranial bones after birth is abnormal. It is most fre- 
quently seen in premature and in syphilitic infants. 

Closure of the Fontanels. — The posterior fontanel is usually oblit- 
erated by the end of the second month. The anterior fontanel under 
normal conditions closes on an average at about the eighteenth month. 
The usual variations are between the fourteenth and twenty-second 
months. At the end of the first year the fontanel is generally about 
one inch in diameter. An open fontanel at the end of the second year 
may be considered abnormal. The closure of the fontanel is not al- 
ways early in well-nourished children, nor is it always delayed in those 
suffering from malnutrition. In very rare cases the anterior fontanel 
may either be closed at birth or may close during the first few weeks of 
life. Closure of the fontanel by the middle of the first year is often seen 
in cases of arrested cerebral development. This indicates a serious con- 
dition, usually microcephalus. Closure of the fontanel in the early 
months of the second year may be due to the slow growth of the 
brain in a child suffering from general malnutrition but otherwise 
normal. 

By far the most frequent cause of delayed closure of the fontanel is 
rickets, in which condition it may be open up to the end of the third 
year. A large fontanel is one of the striking featured of cretinism, and 



THE HEAD 



23 



in untreated cases is often seen as late as the eighth year or later. In 
infancy an open fontanel with a rapid growth of the head should at 
once suggest hydrocephalus. There is an hereditary condition in which 
the fontanel remains open even to adult life. Two such cases in father 
and son were shown us by Marie in Paris. In both there was also lack of 
union between the two portions of the clavicle. 

Shape of the Head. — The deformity which results from compression 




Fig. 3. — Premature Ossification of the Sagittal Suture. Death at six weeks. 



during labor usually disappears by the end of the first month. During 
the first year the head often becomes flattened at the occiput in conse- 
quence of the child's lying too much upon the back. This is easily 
remedied by changing his position. A slight obliquity of the head may 
result from a habitual position during nursing or sleep. A marked de- 
gree of obliquity is sometimes congenital, but usually disappears by 
the third or fourth year. 

The other abnormalities in the shape of the head are chiefly due to 
rickets and hydrocephalus, more rarely to congenital malformations of 
the brain. They will be considered in the chapter devoted to these topics. 



24 GROWTH AND DEVELOPMENT 

Premature ossification of the sutures of the cranium occasionally 
gives rise to striking deformities of the head. Depending upon the 
sutures involved the head may be long and narrow or it may be short and 
high. These two types are known respectively as scaphocephaly and oxy- 
cephaly. They are referred to more fully in the chapter upon Internal 
Hydrocephalus. Fig. 3 shows a skull with complete obliteration of the 
sagittal suture. In this case there was a wide separation of the sutures 
at the junction of the parietal and temporal bones. Premature ossifica- 
tion of the os tribasilare at the base of the skull is largely responsible for 
the prognathism and peculiar formation of the cranium seen in chondro- 
dystrophy. 



THE CHEST 

The figures showing the circumference of the chest at the different 
periods of childhood have already been given. The measurements up to 
and including five years are from personal observations, those from the 
sixth to the sixteenth are taken from Porter, and are drawn from obser- 
vations on 31,371 school children. The measurement of the chest is that 
taken midway between full inspiration and expiration, and at the level 
of the nipples. 

In the newly-born child the antero-posterior and the transverse diam- 
eters of the chest are nearly the same. As age advances, the transverse 
diameter increases very much more rapidly, so that the outline of the 
chest gradually assumes an elliptical shape, which it maintains during 
childhood. 

At birth, the circumference of the chest is about one-half inch less 
than that of the head, but throughout infancy the two measurements are 
nearly the same. It is not until the third year that the average cir- 
cumference of the chest exceeds that of the head. The chest measure- 
ment in infants is always much modified by the amount of fat ; but, after 
making due allowance for this, a large chest always indicates a robust 
child and a small chest a delicate one. If at any age the circumference 
of the child's chest is found to be below the average, means should be 
taken, by gymnastics and otherwise, to develop it. 

In infants deformities of the thorax result chiefly from rickets, some- 
times from empyema, emphysema, and cardiac disease ; in older children, 
from lateral curvature of the spine, or from Pott's disease. A peculiar 
deformity, usually congenital, but sometimes rachitic, is the funnel- 
shaped chest, the Trichter brust of the Germans. It consists in a deep 
pitlike central depression at the lower end of the sternum. It is usually 
permanent. 



MUSCULAR DEVELOPMENT 25 



THE ABDOMEN 

Throughout infancy the circumference of the abdomen is, as a rule, 
about the same as that of the chest. At the end of the second year 
the measurements of the head, chest, and abdomen are very often identi- 
cal; after this time the chest measurement increases much more rapidly 
than the other two. Marked enlargement of the abdomen is seen in 
many varieties of chronic intestinal disorders. The tympanites that 
often accompanies rickets is a frequent cause of enlargement. 



MUSCULAR DEVELOPMENT 

The first voluntary movements are usually in the fourth month, when 
the infant deliberately attempts to grasp some object placed before him. 
During the fourth month, as a rule, the head can be held erect when the 
trunk is supported. In many infants this is possible in the early part 
of the third month. At seven or eight months a healthy child is usually 
able to sit erect and support the trunk for several minutes. 

In the ninth or tenth month are usually seen the first attempts to 
bear the weight upon the feet. At eleven or twelve months a child 
usually stands with slight assistance. The first attempts at walking are 
commonly seen in the twelfth or thirteenth month. The average age at 
which children walk freely alone has been, in our experience, the four- 
teenth or fifteenth month. Quite wide variations are seen in healthy 
children. Very much depends upon the surroundings. We have known 
infants to walk at ten months and many others not until seventeen or 
eighteen months, although showing no evidences of disease, and although 
their development had not been retarded by previous illness. A very 
marked difference is seen in different families with respect to the time 
of walking. 

The physician is often consulted because of backward muscular de- 
velopment, most frequently because the child is late in walking. General 
malnutrition, or any other severe or prolonged illness, may postpone for 
several months this or any of the other functions mentioned. When 
there is no such explanation of the backwardness, a child who does not 
hold up his head, sit alone, or make efforts to stand or walk at the proper 
time, should be submitted to a careful examination for mental deficiency 
or cerebral or spinal paralysis, but especially for rickets, which is the 
most frequent explanation of the symptoms. 

Contrivances for teaching infants to walk are unnecessary, and their 
effect may even be injurious. An infant should be allowed the greatest 
possible freedom in the use of his limbs. He should not be restrained 



26 GROWTH AND DEVELOPMENT 

from walking when inclined to do so, nor continually urged to walk when 
no voluntary attempts are made. Nothing short of mechanical restraint 
will prevent a healthy child from walking or standing when he is strong 
enough to do so. 



DEVELOPMENT OF THE SPECIAL SENSES 

Sight. — The newly-born infant avoids the light. The pupils contract 
in a light room, and if a bright light is brought before the eyes they 
close. During the first few weeks the infant indicates by every sign that 
excessive light is unpleasant. As early as the sixth day the eyes will 
sometimes follow a light in the room, and the child may even turn the 
head for this purpose. The muscles of the eyes of the newly-born infant 
act irregularly and not in harmony. Coordinate action for general pur- 
poses is not established until about the end of the third month. Even 
after this time incoordinate action is occasionally seen. The eyelids 
also move irregularly, and are often partly separated during sleep. The 
cornea is but slightly sensitive during the first weeks. In Preyer's child 
it was not until the third month that the lids closed when the water in 
the bath touched the lashes or the cornea. The recognition of objects 
seen is usually evident in the sixth month. 

It is important that the room in which the newly-born child is placed 
should be darkened, and that for the first few weeks the eyes should be 
protected against strong light. 

Hearing. — For the first twenty-four hours after birth infants are 
deaf. This deafness sometimes persists for several days. It is believed 
to be due to absence of air from the middle ear and to swelling of the 
mucous membrane which lines the tympanum. With the movements of 
respiration, air gradually finds its way into the middle ear, and the swell- 
ing subsides during the first few days. After this the hearing gradually 
improves, and during the early months of life it is very acute. The child 
starts at the slamming of a door, and even moderately loud noises will 
waken him from sleep. By the end of the second month he will some- 
times turn his head in the direction from which the sound comes, and 
by the end of the third month this will usually be done. Demme found. 
in observations upon one hundred and fifty infants, that voices were 
recognized on an average at three and a half months. 

Not only are the ears unusually sensitive to sound in infancy, but 
the impression produced upon the brain is often marked — very loud 
sounds causing great fright. 

Touch. — Tactile sensibility is present at birth, but is not highly de- 
veloped except in the lips and tongue, where it is very acute for the obvi- 



SPEECH 27 

ous necessity of sucking. After the third month it is fairly acute over 
the surface of the body generally. Two especially sensitive areas, 
according to Preyer, are the forehead and external auditory meatus. 

Sensibility to painful impressions is present in early infancy, but 
very dull as compared with later childhood. 

Temperature is also distinguished. This recognition is especially 
acute in the tongue. A young infant is often seen to refuse to take the 
bottle because the milk is only a few degrees too cold or too warm. 

The localization of sensory impressions comes later, probably not 
much before the middle of the sixth month, and is very imperfect 
throughout the first year. 

Taste. — This is highly developed, even from birth. According to the 
experiments of Kussmaul, the ability to distinguish sweet, sour and bit- 
ter, exists in the newly-born child — sweet exciting sucking movements, 
and bitter, grimaces. A young infant detects with surprising accuracy 
the slightest variation in the taste of his food, and the smallest difference 
is often enough to cause him to refuse the bottle altogether. Sweet sub- 
stances are always easily administered, and in combination with syrups 
even very bitter substances can be given; but to aromatic powders and 
elixirs he usually objects. 

Smell. — Observations upon the sense of smell in newly-born infants 
are few and not altogether conclusive. Kroner's experiments appear to 
show that smell is present in the newly born. It has been noted to be 
especially acute in infants born blind. The sense of smell is developed 
much later than the other senses. Detection of fine differences in odors 
is not acquired until quite late in childhood. 



SPEECH 

There is a very wide variation in children with reference to the time 
of development of the function of speech. Girls, as a rule, talk from 
two to four months earlier than boys. Towards the end of the first 
year the average child begins with the words "papa," "mamma." By 
the end of the second year he is able to put words together in short 
sentences of two or three words. Progress in speech from this time is 
very rapid, each month showing great improvement. Names of persons 
are commonly first acquired, then the names of objects. Next to this 
the verbs are learned, and then adverbs and adjectives. Conjunctions, 
prepositions, and articles follow in order, and last of all the personal 
pronouns. 

If a child of two years makes no attempt to speak, some mental defeel 
may usually he inferred or thai the child is a deaf nude. 



GROWTH AND DEVELOPMENT 



DENTITION 



The teeth are enclosed at birth in dental sacs which are situated in 
the gums. Superficially they are covered by the submucous connective 
tissue and the mucous membrane; the dental sacs rest in depressions in 
the alveolar process of the jaw. The tooth grows in length mainly as the 
result of the calcification of its roots, and being thus fixed below, it 
pushes upward towards the mucous membrane. This growth undoubtedly 
goes on steadily from birth until the tooth pierces the gum. 

The deciduous or milk teeth are twenty in number. The time at 
which they appear is subject to considerable variation even under normal 
conditions. The following is the order and the average time of appear- 
ance of the different teeth: 

(1) Two lower central incisors 6 to 9 months. 

(2) Four upper incisors 8 " 12 " 

(3) Two lower lateral incisors and four anterior molars 12 " 15 " 

(4) Four canines 18 " 24 " 

(5) Four posterior molars 24 " 30 " 

At 1 year a child should Lave 6 teeth. 

At 1% years " " " 12 " 

At 2 " " " " 16 " 

At 2% " " " " 20 " 

Quite wide variations on both sides of the average are common, and 
are not always easy of explanation. In many cases it seems to be a family 
idiosyncrasy, since in the different members of a family the teeth are 
apt to appear at about the same time. The order in which the teeth 
appear is much more regular than the time )f their appearance. Slight 
variations are exceedingly common, but marked irregularities in the 
order of the appearance of the teeth are th rule in idiotic children or 
those suffering from slighter mental defects. 

The teeth may pierce the gum without any local manifestations. 
Very frequently, however, just before a tooth comes through there is 
noticed a moderate swelling and redness of the mucous membrane of the 
gum overlying it, and to a slight degree this may affect the general 
mucous membrane of the mouth. This condition may be accompanied 
by a little fretfulness and increased salivation, or both of these may be 
entirely wanting. These symptoms usually disappear when the tooth 
has pierced the gum. The symptoms of difficult dentition will be dis- 
cussed in connection with Diseases of the Mouth. 

Infants may be born with teeth. We know of one family in which 
this occurred in three members of three successive generations. It is, 
however, rare. It is almost invariably one of the lower central incisors 



DENTITION 20 

that is present. In case this interferes with nursing, or if it is very 
loosely attached to the gum, it should be extracted, hut under other 
circumstances it should be allowed to remain, since, if it is removed. 
a second tooth is not likely to appear in its place in the first set. It is 
not at all uncommon for the first teeth to appear in the fourth month. 
Such teeth, in our experience, do not usually differ in character from 
those appearing later, unless they are in children who are syphilitic. 
Syphilitic children are rather prone to early dentition, and under such 
circumstances rapid and early decay is likely to take place. Nursing 
infants are, as a rule, a little earlier in their dentition than those arti- 
ficially fed. 

Delayed dentition is usually due to rickets. However, in many 
healthy infants no teeth appear before the tenth month; and we have 
occasionally seen the first ones at thirteen months in those who seemed 
perfectly healthy and showed no other evidence of rickets. On the other 
hand, it is by no means invariable that dentition is late in rachitic chil- 
dren. The latest dentition is seen in cases of cretinism. In such chil- 
dren it is not rare for the first teeth to appear as late as eighteen 
months or two years. As a rule, dentition and ossification of the bones 
of the head go on in a corresponding manner; where one is early the 
other is likely to be rapid, and conversely. Great irregularities in denti- 
tion are common in children with defective cerebral development. 

Provided an infant is well nourished and"" thrives properly for the 
first six or eight months, the eruption of the teeth is likely to go on 
steadily after this time, even though the child may later have chronic 
indigestion or suffer from extreme malnutrition from any cause except 
rickets. If, however, the symptoms of malnutrition date from birth, 
dentition is almost invariably delayed. It is often a matter of very 
great surprise to see children who are markedly emaciated as a result of 
chronic indigestion or ileocolitis and yet go on cutting their teeth reg- 
ularly. We once had under our care a delicate infant of sixteen months, 
whose body length was twenty-eight inches and whose weight was less 
than nineteen pounds — almost exactly what they were eight months previ- 
ously — and yet he had thirteen teeth. 

Eruption of the Permanent Teeth.— The first to appear are the first 
molars, which usually come in the sixth year, and hence the name six 
year old molars, which is applied to them. These appear posterior to tin 1 
second molars of the first set. 

The incisors and canines replace the corresponding teeth of the firsl 
set. The eight bicuspids take the place of the eight molars of the lirst 
set. The molars of the permanent set appear back of the bicuspids, room 
being made for them by the growth of the jaw. As they grow and push 
upward the permanent teeth cause atrophy of the roots of the firsl teeth, 
3 



30 GROWTH AND DEVELOPMENT 

and gradually cut off their blood supply, so that they loosen and fall out. 
The following table from Forehheimer gives the average time of the 
appearance of the second teeth : 

First molars 6 j'ears. 

Incisors 7 to 8 

Bicuspids 9 " 10 

Canines 12 " 14 

Second molars 12 " 15 

Third molars 17 " 25 

The place of dentition as an etiological factor in the diseases of in- 
fancy will be considered in the chapter on Difficult Dentition. 



CHAPTER III 
PECULIARITIES OF DISEASE IN CHILDREN 

In many particulars disease in children differs from that of later life. 
These differences relate to etiology, pathology, symptomatolog} f , diagno- 
sis, and prognosis. The greatest contrast to adult life is presented by 
infancy and early childhood. After seven years, children in their diseases 
resemble adults more than they do infants. 

ETIOLOGY 

1. Inheritance is an important factor. The disease most frequently 
transmitted directly is syphilis. Occasionally tuberculosis and other 
infectious diseases have been conveyed directly from the mother to the 
child. In cases where no distinct disease is transmitted, children may 
inherit from parents constitutional weaknesses or tendencies, which may 
manifest themselves in infancy, or in some cases not until later child- 
hood. Under this head we may place the influence of alcoholism, lead 
poisoning, rheumatism, gout, epilepsy, and insanity. 

2. Malformations must be considered, particularly in the first two 
years of life. The most important of these, from a medical standpoint, 
are those of the heart, brain, stomach and intestines, and kidney. The 
various malformations of the mouth, nose, bladder, rectum, and genital 
organs belong more particularly to the domain of surgery. 

3. The Diseases or Accidents Connected with Birth. — Some of these 
are distinctly traumatic, like the meningeal hemorrhages. A very large 
class are the infectious processes in the newly born. Infection usually 






SYMPTOMATOLOGY AND DIAGNOSIS 31 

takes place through the umbilical wound, more rarely through the skin 
or mucous membranes. This class includes pyemia, with its varied 
lesions in the brain, lungs, and serous membranes, erysipelas, ophthalmia, 
and tetanus. In the class of infectious diseases may also be included 
many of the varieties of pulmonary and intestinal diseases in the newly 
born, and probably also some of the hemorrhagic affections. 

4. Conditions Interfering with Proper Growth and Development. — 
These are among the largest etiological factors in the diseases of infancy. 
They are improper food or feeding, unhygienic surroundings, and neglect. 
These may cause specific diseases, like rickets or scurvy, or may lead to a 
condition of general malnutrition or marasmus. In this way they become 
most important predisposing factors, in infancy, to the acute diseases of 
the gastro-enteric tract, and later in childhood, to functional nervous 
diseases. 

5. Infection. — This has already been mentioned as an important 
factor in diseases of the newly born. The number of diseases in later 
life directly traceable to this is very large. Under this head should be 
included not only the well-known classes of infectious and contagious 
diseases, but also a very large number of varieties of infection which 
as yet have not been differentiated, and the nature of which is but im- 
perfectly understood. 



SYMPTOMATOLOGY AND DIAGNOSIS 

In older children the symptoms of disease are Very much the same as 
in adults, and similar methods of examination may be employed. What 
is really peculiar to children belongs especially to the first three years of 
life, before speech has developed. During this period the chief and 
almost the sole reliance of the physician must be upon the objective 
signs of the disease. It is not so much that diseases in early life are 
peculiar, as that the patients themselves are peculiar. 

Two fundamental facts are always to be kept in mind : First, that 
the common pathological processes are comparatively few, being chiefly 
of the gastro-enteric tract, the lungs, and the brain, but that the varia- 
tions in clinical types are almost endless ; the second is, that in infants, on 
account of the susceptibility of the nervous system, functional de- 
rangements are often accompanied by very grave symptoms, and may 
even prove fatal in twelve or twenty-four hours, or there may be speedy 
and complete recovery after very alarming symptoms. In many of 
these cases the symptoms are so indefinite that an exact diagnosis is 
impossible during life, and even the autopsy may throw but little light 
upon them. 



32 PECULIARITIES OF DISEASE IN CHILDREN 

At the bedside it is of great assistance to the physician if he can 
keep in mind the most frequent forms of acute disease that are likely to 
be met with. In the first group, including those which are very com- 
mon, may be placed acute indigestion and ileocolitis, bronchitis, pneu- 
monia, pharyngitis, tonsillitis, and otitis media; in the second group, 
which are less frequent, are placed the more common acute infectious 
diseases; in the third group, including the rarer forms of acute disease 
— meningitis, tuberculosis, rheumatism, and diseases of the kidneys. 
In all circumstances, the season, and the nature of the prevailing epi- 
demic, if one exists, are to be considered. 

In the examination of a sick infant quite a different method is to be 
followed from that pursued with adults. Much information is to be 
gained from a history carefully taken from an intelligent mother or 
nurse, and much more from a close observation of the child, whether 
asleep or awake, quiet or crying. 

The History. — In view of the fact that but little information can 
be had from the patient, none at all in most cases, it is important to 
obtain from the mother or nurse as full and complete information as 
possible. A good history carefully obtained, puts the physician in pos- 
session of a fund of information about the patient which is not only of 
the greatest value in arriving at a diagnosis in the illness for which he 
is consulted, but is exceedingly helpful in the future management of the 
child. He may thus know the individual peculiarities and special path- 
ological tendencies. The laity attach great importance, and justly so, 
to advice from the physician who "knows the child's constitution." 
Such a history should be taken at the first opportunity after the physi- 
cian is placed in charge of a child, and with note-book in hand, or half 
its value will be lost. 

Family History. — This should begin with the parents, going farther 
back, if possible, in many cases of hereditary disease. One must know 
regarding tuberculosis, syphilis, rheumatism, or alcoholism, the general 
vigor of constitution and physical condition of both father and mother. 
Health during pregnancy, and previous miscarriages, if any, are im- 
portant facts in the mother's history. One should know the number 
of other children living and their general health, the number dead and 
from what causes. A knowledge of the surroundings in which the child 
has lived may be necessary to appreciate the chances of exposure to 
tuberculosis, malaria, and many other forms of infection. 

Patient's Previous History. — This should begin with birth. One 
should inquire whether the child was premature or born at term, regard- 
ing the character of the labor, whether natural or instrumental, tedious 
or complicated, the condition and vigor of the child at birth, primary 
respirations, early convulsions, and the nutrition during the early days. 



SYMPTOMATOLOGY AND DIAGNOSIS 33 

Xext the methods of feeding should be taken up — how long entirely 
and how long partly breast fed, the date of weaning and the form of 
artificial feeding then employed. If the patient is an infant, and the 
problem presented is one of its nutrition, all the reliable data relating 
to the feeding should be obtained, even to the minutest detail. This 
may be wearisome and consume time, but in no other way can one ap- 
preciate the conditions present. The best idea of the child's growth and 
development may be obtained from a weight record if one has been 
kept. If not available, one must depend upon general statements as 
to how the child thrived at different periods. The date of the appear- 
ance of the first teeth and the time and the order in which the teeth came, 
are significant. The general muscular development may be best de- 
termined by learning when the child could first hold the head erect, 
sit alone upon the floor, bear the weight upon the feet, creep or walk 
alone; the mental development, by learning as to early recognition of 
mother or nurse, knowing the bottle, understanding the meaning of 
words, speaking in words or sentences. The muscular and mental de- 
velopment of a normal child during the first two years is a subject 
with which the physician should be familiar if he would detect early 
those differences, often slight at this age, in children whose development 
is backward owing to cerebral lesions. 

All previous attacks of acute illness of whatever character should be 
noted, particularly the infectious diseases — measles, scarlet fever, diph- 
theria, pertussis, and influenza — with dates and details as to duration, 
severity, and complications. One should learn whether the child is espe- 
cially prone to disorders of digestion or those of the respiratory system. 
Under the former head are included early difficulties in feeding, acute 
attacks of indigestion, diarrhea, or dysentery, also chronic disturbances 
of the stomach or bowels; under the latter head, frequent catarrhal 
colds, earache or otitis, catarrhal croup, bronchitis, pneumonia, or 
pleurisy. Other points to be investigated relate to attacks of tonsillitis, 
operations for the removal of hypertrophied tonsils or adenoids, and 
previous disorders of the nervous system. In infants, particularly im- 
portant are extreme restlessness, insomnia, convulsions, or attacks of 
night terrors; in those who are older, hysterical manifestations, epilepsy, 
or chorea. Finally, one should know the date of successful vaccination. 
Inquiry should also be made concerning any recent exposure to infection 
in the community, school, or home. 

Present Illness. — One should first note the chief complaints as stated 
by mother or nurse. It is important to obtain as definite statements as 
possible as to the time when the child was quite well, and whether the 
onset of the illness was abrupt or gradual, and with what particular 
symptoms. In all digestive disorders one should know exactly concern- 



34 PECULIARITIES OF DISEASE IN CHILDREN 

ing the child's food at the time of the onset, its quantity, character, and 
preparation; also any recent change in diet, the presence or absence of 
vomiting, and the condition of the bowels, whether loose or constipated, 
the frequency and character of the stools. General questions as to 
whether the bowels are regular or the stools normal are of no value, 
since the informant often is not capable of judging correctly. 

Nervous symptoms, like the others, should be elicited in response to 
direct questions regarding sleep, restlessness, moaning, crying out, or 
other evidences of pain, excitement, delirium, or convulsions, or unnat- 
ural drowsiness. In any acute illness other important symptoms are 
fever, sweating, dyspnea, cough, hoarseness, nasal discharge, and the 
amount and character of the urine. 

The Examination. — With infants, quite a different method should be 
followed from that pursued with adults. It may well begin with: 

General Inspection. — What is learned in this way will depend almost 
entirely upon the acuteness of observation of the physician, but much 
that is of value can be ascertained before the clothing is removed for 
the physical examination by simply watching the patient, whether asleep 
or awake, for several minutes. In acute disease, the following points 
should be noted especially: 

1. Nutrition and general development: whether the child is well 
nourished or the features pinched and wasted. 

2. The facial expression : whether it is bright and intelligent or dull 
and stupid, peaceful or anxious, quiet or disturbed, and whether the 
features are contracted from time to time, as if from pain. 

3. The character of the respiration: whether it is rapid or slow, easy 
or difficult; whether there is nasal obstruction, as indicated by snoring 
and mouth-breathing, suggesting in infants acute rhinitis, syphilis, or 
retropharyngeal abscess; in older children, diphtheria, scarlet fever, or 
adenoids. Marked dyspnea is usually accompanied by active dilatation 
of the alae nasi. 

4. The posture : whether the child lies upon the back, side, or face ; 
whether the head is drawn back with general flexion of the extremities 
as in meningitis. 

5. The nervous condition : whether the child is restless, excitable, or 
drowsy and apathetic; if asleep, the nature of the sleep should be 
observed. 

6. The color of the skin of the face: whether pale or cyanotic; and 
the lips, whether fissured or excoriated. 

7. The amount of prostration : a practiced eye can usually tell with 
older children whether the condition is grave or not, but infants not 
infrequently deceive even the most experienced observer. 

8. The cry: in conditions of restlessness or irritability, much infor- 



SYMPTOMATOLOGY AXD DIAGNOSIS 35 

mation may be obtained from its character. It is important, but not 
always easy, to determine whether a child cries from fright, as at the 
approach of a stranger, from nervousness or bad training, from general 
irritability which may come from any acute disease, or from actual 
pain. The cry of fright is usually evident, because it comes with the 
physician's approach and ceases when he goes away. Children of highly 
neurotic parents and those who have been much indulged and badly 
trained will often cry when anything out of the usual routine occurs. 
The cry of pain may be very distinctive ; it may be sharp and acute and 
accompanied by some attempt at localization, as when a child puts his 
hand to an inflamed part, but in infancy the pain of acute inflammation 
is often indicated only by general restlessness and irritability. This is 
frequently true of acute otitis. The cry of pain is usually accompanied 
by contraction of the features and other evidences of distress. 

The cry of some diseases is quite characteristic, as the short, catchy 
cry of acute pneumonia or bronchitis; the hoarse cry of laryngitis, 
whether catarrhal, membranous, or syphilitic; the feeble whine of ex- 
treme exhaustion or marasmus; the moaning cry of intestinal disease; 
and the sharp cry of a child with scurvy whenever its bed or body is 
touched. 

Measurements. — These, though of greatest value in chronic diseases, 
particularly disturbances of nutrition, may be of assistance also in acute 
conditions. The important measurements are the circumference of the 
head, chest, and body length. The circumference of the abdomen is at 
times important, but varies so much with the degree of distention that 
it is not significant as to the general development. The measurements 
and weight furnish reliable data which are not only of assistance in the 
diagnosis of existing disease, but if recorded are useful for future com- 
parison. 

In taking the circumference of the head the largest measurement 
(over the occipital and frontal eminences) is preferable. The measure- 
ment of the chest is usually taken over the nipples. The body length 
of infants is best taken with a tape as the child lies upon his back upon 
a table or a firm bed. For older children a special measuring stick is 
convenient. 

To estimate properly the significance of measurements they should 
be compared with the normal averages and with each other. Tt should 
be remembered that the head is normally larger than the chest until near 
the end of the second year: after this time, with a normal development, 
the chest should be larger. Any great disproportion between the size 
of the head and chest is suggestive of disease. The large head and the 
small chest belong especially to rickets. The measurements form im- 
portant means of recognizing early such abnormalities as cretinism and 



36 PECULIARITIES OF DISEASE IN CHILDREN 

chondrodystrophy, the variations often being marked before the other 
symptoms are prominent. One who forms the habit of taking regular 
measurements soon appreciates the variations from the normal, and gains 
great assistance from these data. Such a record made from year to 
year in children whose development is in any way abnormal is of great 
value in indicating what should be done in the way of exercise to correct 
faulty conditions. 

Vital Signs. — Pulse, Eespiration, and Temperature. — The signifi- 
cance of these signs is not to be measured by adult standards, since the 
susceptible nervous system of infants and very young children greatly 
exaggerates their reaction to all forms of acute infection. 

The rate, regularity, quality, and tension of the pulse should be noted. 
In young children, the rate of the pulse is of less importance than its 
force and quality. A slow, irregular pulse is always significant, and 
should suggest meningitis or brain tumor; a slight irregularity of the 
pulse during sleep has no special significance. The pulse rate is much 
increased from slight disturbances; the approach of a stranger or the 
examination by the physician may cause it to rise 20 or 30 beats. In 
acute disease, a pulse rate of 150 is common, and 170 or 180 is often seen 
where other symptoms are not particularly severe. 

The rate, depth, and rhythm of respiration should be noted. The 
last often cannot be determined except by attentively watching the child 
for several minutes. In premature and very young infants a ti ' er 
marked irregularity may be seen, often approaching the Cheyne-Stokes 
type. It is not to be taken as indicating a cerebral lesion, but seems 
rather to be due to the fact that the respiratory center is not yet fully 
able to control the movements. Eespiration of this type is seen only 
during the first weeks of life. Irregularity of rhythm at other times 
should suggest cerebral disease, usually meningitis. The respiration rate 
is proportionately greater in infants than in adults. In acute diseases 
of the lungs it not infrequently rises to 70 or 80, and occasionally it may 
be over 100 a minute. The rate is generally in proportion to the extent 
of the pulmonary lesion. 

The temperature of infants and very young children should be taken 
in the rectum, since groin or axillary temperatures are untrustworthy 
and those in the mouth difficult to obtain. Immediately after birth the 
temperature of the child is about the same as that of the mother, or a 
little higher. It falls from 1° to 3° F. in the course of the first few 
hours. Soon it again rises to 98.5° or 99° F. 

From a large number of personal observations upon healthy infants, 
we have found that the rectal temperature under normal conditions varies 
between 98° and 99.5° F. ; occasionally the range may ho as wide as 
97.5° to 100.5° F. in apparently perfect health. The heat-regulating 



SYMPTOMATOLOGY AND DIAGNOSIS 37 

center in the brain acts only imperfectly in the young infant, and slight 
causes are enough to disturb the temperature. 

The temperature in infants is always higher than from corresponding 
causes in adults. Moreover, very high temperatures may be met with in 
cases not serious, and not infrequently when no explanation can be 
found even after thorough examination. In such cases the temperature 
seldom remains at a high point for more than a few hours. It is a 
continuous high temperature rather than a single rise which is significant 
of disease in infancy. Nothing is more perplexing to the young practi- 
tioner than the frequency with which a high temperature is seen in 
infants in cases of comparatively mild illness. 

It is common in chronic wasting diseases, in delicate infants and in 
those prematurely born, to find the temperature one or two degrees below 
the normal; 95° and 9G° F. are of almost daily occurrence in hospitals, 
and much lower ones sre not rare. Daily observations should be made 
with the thermometer in such conditions, just as in fever. 

Puzzling and apparently alarming temperatures are seen in infants 
as a result of the application of artificial heat. In one of our patients, 
an infant two days old, a temperature of 107° F. was caused by the 
close proximity of two large hot-water bags placed in the baby's basket. 
The younger and feebler the child the more readily are such temperatures 
produced. 

fuscular and Mental Development. — The general muscular develop- 
ment is determined by seeing how well the children can hold up the head, 
sit alone, stand, or walk; the mental development in young infants, by 
the intelligence of expression, the manner in which they respond to 
stimuli, the recognition of objects, fright at strangers, etc. ; later in the 
first year, by the use of their hands, their understanding of speech, and 
their ability to pronounce words. 

Local Examination. — For the purpose of making a complete routine 
examination of an infant the entire clothing, with the exception of the 
napkin, should be removed, and the infant placed preferably upon the 
nurse's lap upon a blanket. With older children the clothing may be 
removed and the body examined, one part at a time, but with all children 
it is essential that the examination be complete. A warm room is indis- 
pensable, and a table covered with a blanket in many respects • better 
than the nurse's lap, although the latter has usually to be employed. 
The local examination should be deliberate, the physician should pro- 
ceed cautiously, winning the child by gradual approaches, and avoiding 
excitement, force, or anything which may cause pain. 

Shin. — The skin should first be inspected for eruptions, and il is 
important that the entire eruption be examined in order thai the distri- 
bution as well as the character of the lesion may be seen. Marked wrin- 



38 PECULIARITIES OF DISEASE IN CHILDREN 

kling or loss of elasticity of the skin is one of the best indications of loss 
in weight. Bedsores are more frequently seen over the occiput than 
over the sacrum. Any large veins should be noted. 

External glands should now be examined, especially the cervical, 
axillary, inguinal, and epitrochlear. The cause of a marked enlarge- 
ment of any of these groups should be sought in the skin or mucous 
membranes with which they are connected. Marked swelling of the 
cervical glands may indicate diphtheria., scarlet fever, or a simple acute 
inflammation dependent upon a rhinopharyngitis. Enlargement of the 
epitrochlear glands is especially significant of syphilis. General enlarge- 
ment of all the glands to a slight degree is seen in most cases of mal- 
nutrition and in many acute infectious diseases. 

Head. — One should first note whether the sutures are ossified, un- 
naturally open or separated; also whether the fontanel is closed, or, if 
open, whether it is depressed or bulging. Prominences of the frontal 
or parietal regions when symmetrical are indicative of rickets. Irregular 
prominences of a smaller size, when present, are usually syphilitic. In 
the newly born, a tumor on the head, if in the median line, may indi- 
cate an encephalocele ; if limited to either the parietal or occipital bone 
it is usually a cephalhematoma. 

Eyes. — The condition of the conjunctivae and lids should be noted, 
also the presence of ptosis, strabismus, or other paralysis, but particularly 
the condition of the pupils, whether contracted or dilated, and the nature 
of their response to light. One should look also for the presence of 
corneal ulcers or of interstitial keratitis frequently seen in late hereditary 
syphilis. 

Ears. — The presence of a discharge may be recognized by sight or 
by the odor. In any acute febrile condition one should look for tender^ 
ness or swelling over the ear or mastoid. The ears should invariably be 
examined otoscopically in all forms of febrile disturbance whose cause 
is doubtful and from time to time in pneumonia, scarlet fever, measles, 
diphtheria and other diseases involving the mouth and rhinopharynx. 

Nose. — The presence of any nasal discharge should be noted and its 
character determined. An abundant discharge tinged with blood, in 
young infants, should suggest syphilis; in older children, diphtheria; a 
chronic discharge, adenoid growths; a purulent discharge of one side, 
a foreign body. 

Mouth. — The appearance of the mucous membrane of the mouth 
and gums as well as the teeth may often be ascertained by watching 
the child while he is crying. It should be noted whether the tongue is 
dry or moist, clean or coated ; whether thrush is present or any other 
form of stomatitis. If the gums are congested, swollen, or hemorrhagic, 
they should suggest scurvy. The number, position, and character of 



SYMPTOMATOLOGY AND DIAGNOSIS 39 

the teeth are important. The general color of the mucous membrane 
may be significant in cases of cyanosis in congenital cardiac disease, and 
extreme pallor of the mucous membrane in anemia. On the mucous 
membrane of the hard palate may often be found the first local evidence 
of scarlet fever in the form of a minute punctate eruption, and on that 
portion of the cheeks opposite the molar teeth should be sought Koplik's 
sign, the earliest reliable symptom of measles. 

Throat. — A careful examination of the pharynx and tonsils should 
never be omitted in any acute illness, no matter what other symptoms 
may be present. Xot only tonsillitis, but often diphtheria, is overlooked 
from a failure to observe this as an invariable rule. A good light is 
essential, and one must train himself to take in all the appearances at 
a single glance. Marked general redness of the pharynx may be asso- 
ciated with scarlet fever, influenza, or simple acute pharyngitis. If other 
symptoms are present pointing to chronic nasal obstruction or to a 
catarrhal process of the rhinopharynx, a digital examination should be 
made to determine the presence of adenoids. Dyspnea with mouth- 
breathing when associated with difficulty in swallowing should, in an 
infant, always suggest retropharyngeal abscess. The examination of the 
mouth and throat may wisely be made the last step, since it usually 
disturbs a child so as to embarrass further investigation. 

Neck. — One should consider the position in which the head is held 
and the amount of rigidity of the cervical muscles. Opisthotonus may be 
associated with meningitis or old cerebral palsy. A marked rigidity may 
indicate cervical Pott's disease or, if accompanied by torticollis, may 
be of rheumatic origin. 

Chest. — In young children particular importance should be attached 
to the shape of the chest. Symmetrical deformities are usually due to 
rickets. Contraction of one side only is most frequently the result of 
an old empyema or an extensive interstitial pneumonia. Bulging of the 
precordial region is frequent in cardiac disease. One should notice also 
the recession of the soft parts — intercostal spaces, the suprasternal notch. 
or the epigastrium; the amount of this is usually the best means of 
judging the severity of obstructive dyspnea. Details regarding the 
physical examination of the lungs are discussed in the introductory chap- 
ter to Pulmonary Diseases. 

I I carl. — It should be remembered that under two years old loud 
murmurs are almost invariably of congenital origin, that soft murmurs 
at the base are very frequently functional, and that acquired cardiac 
disease is rare until after three years. For further details in the ex- 
amination the reader is referred to the chapters upon Diseases of the 
Heart. 

Abdomen. — There should be noted the presence or absence of tym- 



40 PECULIAPxITIES OF DISEASE IN CHILDREN 

panites or abdominal tenderness, whether general or localized, and the 
existence of retraction of the abdominal walls as in meningitis. The 
size and position of the liver and spleen are best determined by palpa- 
tion. The lower border of the liver is usually slightly below the free 
border of the ribs. If the spleen can be easily felt below the ribs, it is, 
as a rule, enlarged. If it can not be felt in a satisfactory examination, 
it is not sufficiently enlarged to be of any diagnostic importance. In 
acute disease a large spleen suggests malaria, typhoid, or tuberculosis; 
in chronic disease, rickets, malaria, syphilis, leukemia, or anemia. 

Spine. — The most frequent spinal curves seen in infancy are those 
due to muscular weakness. These disappear by placing the child in a 
prone position. Rachitic curvatures are of the same general character, 
but as they have usually lasted a longer time the spine is less flexible 
and the curvatures may not entirely disappear by change of posture. An 
angular deformity or even marked rigidity of the spine should suggest 
Pott's disease. 

Extremities. — The color of the skin and the character of the periph- 
eral circulation should be noted especially in pneumonia, diphtheria, and 
other diseases attended by weakened heart. Clubbing of the fingers or 
toes may be due to congenital heart disease or to chronic disease of the 
lungs. Desquamation of the palms or soles may indicate hereditary 
syphilis or scarlet fever, even though no other evidence may be present. 
The finger-nails may give valuable information in hereditary syphilis. 
In examining the extremities one should note especially the presence 
of tenderness, flaecidity, or rigidity of muscles, whether the limbs 
are wasted or plump, and the degree of muscular power; also any 
abnormal swelling on the shaft or near the extremities of the bones, and, 
finally, the function of the joints. A general relaxation of the liga- 
ments is common in rickets, in paralytic conditions, and in the Mon- 
golian type of mental deficiency. Flabbiness of the muscles belongs to 
malnutrition and rickets; rigidity, if chronic, is usually indicative of 
cerebral palsy. Weakness of special groups, with atrophy and flaccid 
muscles, suggests poliomyelitis. Acute tenderness of the legs in in- 
fants should suggest scurvy; in older children, osteomyelitis or rheuma- 
tism. Rachitic deformities are almost invariably bilateral. Tuber- 
culous bone disease affects the epiphyses, while syphilis usually involves 
the shafts, the only exception to this being the epiphyseal separation 
which may occur in the first months of life. 

The reflexes may be somewhat difficult to obtain in infants and when 
exaggerated may indicate cerebral palsy, meningitis, or, as in tetany, only 
an extreme irritability of the nervous centers without organic disease. 
The plantar reflex of Babinski has little significance in infants, and in 
older children it is present in many conditions. Kernig's sign is a form 



PATHOLOGY 41 

of muscular spasm almost invariably present in meningitis, but often 
seen in other diseases. 

Genital Organs. — Male children should be examined to determine the 
presence of phimosis or of undescended testicles. Hydrocele of the cord 
is a frequent condition, and may be mistaken for hernia. Both inguinal 
and umbilical herniae are very common. In female children it should be 
remembered that preputial adhesions may be considered normal, and are 
seldom the cause of the nervous symptoms attributed to them. Every 
vaginal discharge is significant, and if purulent should be examined 
bacteriologically. The great frequency of gonococcus infections is not 
appreciated, and they may be found when least expected. 

The examination is not complete without the inspection of the stools, 
the chemical and microscopical examination of the urine, and an exami- 
nation of the blood. All are more fully considered in special chapters. 

PATHOLOGY 

The pathological processes which result from intra-uterine disease 
and those which are connected with delivery are peculiar to early life. 
They have already been referred to in the section on etiology. Of the 
processes of early life which begin after birth, the first in frequency 
are those of the mucous membranes resulting from the various forms of 
irritation and infection. In summer, it is the stomach and intestines 
which suffer chiefly; in winter, the respiratory tract. 

The serous membranes are rarely the seat of primary inflammation. 
The pleura is seldom the seat of primary disease, but is very often in- 
volved secondarily to disease of the lung itself. Affections of the peri- 
cardium and peritoneum are quite rare. Meningitis is fairly common, 
especially the tuberculous form. 

Diseases of the lymph nodes (lymphatic glands) play an important 
part in connection with the acute diseases of the mucous membranes, 
with many affections of the skin, and even of the viscera. Acute infec- 
tion tends to excite suppurative inflammation, particularly in infants; a 
less active process leads to chronic hyperplasia in the mesenteric, medias- 
tinal, and cervical glands, in the tonsils, adenoid tissue of the pharynx, 
etc. The lymph nodes in the neck and thorax are frequently the earliest 
seat of tuberculous deposits, and in very many cases they are the foci 
from which secondary infection of the lungs, brain, or joints may occur. 

Of the visceral inflammations those of the lungs are the most com- 
mon, it being rare to find the lungs normal at autopsy after any acute 
infectious disease which has lasted a week. Up to the third or fourth 
year of life the heart usually escapes. In older children it may be in- 
volved, as in adults, in the rheumatic diseases. The liver and spleen 



42 PECULIARITIES OF DISEASE IN CHILDREN 

are not often the seat of organic disease in early life, nor is serious disease 
of the kidney likely to be met with except in connection with scarlet 
fever. Organic disease of the brain itself is rare, as is also organic 
disease of the spinal cord, with the exception of poliomyelitis. Chronic 
diseases of the different viscera are decidedly rare, except when resulting 
from acute processes. Diseases of the bones and joints are common, and 
of extreme importance. They are usually of tuberculous, less frequently 

The following table gives in a general way a very good idea of the relative 
frequency of diseases of the different organs in infancy. It is based upon seven 
hundred and twenty-six consecutive autopsies in the New York Infant Asylum, 
extending over a period of eight years during our connection with that institution. 
Of these children seventy-two per cent were under one year, twenty-five per 
cent between one and two years, and only three per cent were over two years. 
The institution did not receive infants under one month, hence the absence of 
lesions peculiar to the newly-born: 

Table showing principal lesions in seven hundred and twenty-six con- 
secutive autopsies in the New York Infant Asylum. 
Lungs : 

Pneumonia — Primary 139 

Complicating other acute infectious diseases 112 

Complicating other conditions 71 

Noted to be present in 322 

Pleurisy — No case uncomplicated with disease of lungs. 

Empyema 5 

Serous pleurisy 1 

Dry pleurisy in nearly all the severe cases of pneu- 
monia. 

Atelectasis (congenital) 6 

Pulmonary abscess (always with pneumonia) 7 

Pulmonary gangrene (always with pneumonia) 2 

Pulmonary tuberculosis 56 

Mouth: 

Noma 1 

Peritoneum: 

Acute peritonitis (localized 2, with acute pneumonia and pleurisy 

2) 4 

Kidneys: 

Acute nephritis (complicating scarlet fever 4, diphtheria 1, pneu- 
monia 4, measles 1, pertussis 1, ileocolitis 2, pyonephrosis 1, 

apparently primary 5) 19 

Malformations of the kidney 7 

Stomach and Intestines: 

Acute ileocolitis, with or without gastritis. . . . ." 116 

A.cute gastritis (without intestinal lesions) None 

Acute diarrheal disease (without gross lesions) 72 

Intussusception 1 



PROGNOSIS AND INFANT MORTALITY 



43 



of syphilitic, origin. Diseases of the hlood are quite common, hut as 
yet hut little understood. New growths are rare. The parts most fre- 
quently affected are the kidneys and the bones. Disorders of nutrition 
are extremely common and of great importance, particularly rickets and 
scurvy. 

PROGNOSIS AND INFANT MORTALITY 

The younger the patient the worse the prognosis in all the diseases of 
childhood. This is in consequence of the feeble resistance of the infan- 
tile organism to all diseases, particularly those which are of an acute 
nature. On the other hand, the rapid metabolism of childhood makes 
it possible for many conditions of an organic nature to disappear with 
time, or, as the phrase is, to be "outgrown," provided the patient can 
be so placed that the general nutrition can be carried to the highest 
point. 

The accompanying chart (Plate I) shows the mortality of New York 
•City by months during three consecutive years, representing a total 
mortality of 128,136. 

The following table gives comparative figures of actual deaths for 
four periods of three years each, and shows the reduction in infant and 
child mortality which has taken place in the last twenty-five years : 

Deaths — New York City (Boroughs of Manhattan and Bronx) 



Under 1 year. 

1 to 2 years . 

2 " 5 " 
5 " 15 " 
Over 15 " 

Total 



1890-1892. 



32,916 = 26% 

10,547= 8% 

9,794= 7% 

5,470= 5% 

69,409 = 54% 



128,136 



1898-1900. 



24% 
7% 



29,326 
9,012 

7,292— u 70 
6,922= 5% 

71,024 = 58% 



123,576 



1907-1909. 



30,626 = 22.5% 
8,298= 6.0% 
6,579= 5.0% 
4,902= 3.5% 

85,741 = 63.0% 



136,146 



1912-1914. 



25,015 = 19.1% 

6,527= 5.0% 

5,408= 4.1% 

4,533= 3.5% 

89,341 = 68.3% 



130,824 



Heart : 

Pericarditis (all with acute pneumonia) 3 

Congenita] malformations ....'. 3 

Acute or chronic endocarditis None 

Brain : 

Acute meningitis (7 with pneumonia, 2 cerebrospinal) 14 

Tuberculous meningitis 11 

Acute encephalitis 1 

Chronic pachymeningitis 5 

Chronic meningitis 1 

Chronic hydrocephalus 3 

There were twenty-six dniths from marasmus withoul gross lesions. 



44 



PECULIARITIES OF DISEASE IN CHILDREN 



The deaths per 1 7 U00 of population show the same reduction. The 
curves for the different age periods are indicated in the accompanying 
chart (Fig. 4). 

The reduction in infant mortality in New York has heen chiefly in 
acute gastro-intestinal diseases, marasmus and debility, especially in 
those over three months old. In older children it has been chiefly in 
acute infectious diseases, especially diphtheria. The mortality from 





1887 1890 1393 1896 1899 1902 1905 1908 
















































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Fig. 4.— Deaths — New Yokk City — per 1,000 of Population. 



certain other causes is increasing, notably acute respiratory diseases and 
prematurity. 

The only age in which the mortality is increased during the summer 
months is the first yeah In Fig. 5 are given the curves indicating the 
deaths under one year and from one to live years by months. 

The rise in the summer mortality during the first year is chiefly 
due to diarrheal diseases. As a, result of the organized campaign for 
the reduction of infant mortality in New York which has been in full 
operation since 1911, the number of infant deaths has steadily fallen. 
That part of the mortality curve chiefly affected has been the sharp 
summer rise which has been almost obliterated. Tt will be noted that 
the curve for children from one to five years of age touches the highest 
point in the late winter and early spring months, the time when pneu- 
monia and the common contagious diseases are most prevalent. The 



PLATE I 



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CHILDREN UNDER 1 YEAR 
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2 TO 5 YEARS. 
5 TO 15 YEARS 

Over 15 years. 










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Chart Showing by Months the Mortality of New York City for the Dif- 
ferent Ages for Three Consecutive Years. Scale, 1 in. — 2,200 deaths. 



PROGNOSIS AXD IXFAXT MORTALITY 



45 





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46 



PECULIARITIES OF DISEASE IN CHILDREN 



curve for both groups is lowest in the months of October and November, 
which may therefore be considered the healthiest months in New York. 
The highest mortality is in the first month of age. During this time 
twenty-five per cent of the deaths of the first year occur. Eross, writing 
in 1894, states that from the records of sixteen large cities of Conti- 
nental Europe nearly ten per cent of all the infants born died during 
the first month. These figures have been considerably reduced since 
that time. 1 The first weeks of life are the period of highest mortality, 
because in them takes place the adaptation of the organism to its environ- 
ment. After this period each month shows a steadily declining death 
rate to the end of the first year. 

Causes of Death, at Different Periods. — The most frequent causes of 
infant mortality, according to the combined reports from the records of 
the cities of New York, Philadelphia, Boston, and Chicago, making a 
total of 44,226 deaths in the first year, are shown in the accompanying 
chart (Fig. 6). 

The group, acute gastro-intestinal, includes chiefly diarrheal diseases 
in summer. The proportion of deaths from this cause is being greatly 
reduced; while the proportion due to acute respiratory diseases, chiefly 
pneumonia and bronchitis, is increasing. Marasmus, prematurity, etc., 
include also congenital debility, inanition, and other conditions in which 
the cause of death recorded is disorder of nutrition rather than some 
general or local disease. The group, congenital malformations, includes 

1 The relative frequency of the causes of death in the newly born has been 
greatly altered since the introduction of antiseptic midwifery. Some idea of the 
importance of the different factors has been gained from a study of the records 
of the Sloane Hospital for Women for a period of six years (1908-1914), embrac- 
ing 10,000 consecutive births. 

CAUSES OF DEATH DURING FIRST FOURTEEN DAYS 



Congenital weakness 
Accidents of labor . . 

Pneumonia 

Atelectasis .-.••■ 

Congenital syphilis . 

Malformations 

Hemorrhage 

Sepsis 

Asphyxia 

Accidental 

Undetermined 

Totals 



Under 
One Day 



Under 
7 Days 



102 38 135 98 



120 
1 
3 
3 
6 



Seven to 


Total Under 


14 Days 


14 Days 


14 2 


134 9 




1 32 


3 13 


6 22 


1 7 


4 21 


6 


12 1 


3 


2 10 


2 


.. 10 


7 


P, 




8 




2 




8 


24 34 


159 132 



Grand 
Totals 



143 
33 
28 
25 
13 
12 
10 



291 



Ten thousand confinements: Abortions, 253; stillbirths, 429; living births, 9,318. 
heavy type.) Holt and Babbitt, Jour. American Med. Assn., Jan. 25, 1915. 



(Prematures, 



Nearly half of the total mortality for the period covered was ascribed to 
congenital weakness, chiefly due to prematurity. 



PROGNOSIS AND TXFAXT MOPxTALITY 



47 



also deaths from accidents during birth. Whooping cough is the most 
important member of the group of acute infectious diseases, diphtheria 
coming next. Tuberculosis should, we believe, be rated higher than is 
shown in these figures. The mortality records of the Babies' Hospital 
show that the deaths from tuberculosis constitute 5.6 per cent of the 
first-year mortality of that institution. 

The figures and charts preceding indicate that a very marked re- 
duction in infant and child mortality has taken place especially within 
the last twenty years. Many causes have united to bring about this 
result. Among those which have affected infants may be mentioned: 



CHIEF CAUSES OF DEATH FIRST YEAR. 




ACUTE GASTRO INTESTINAL 28.0 PER CENT. 




MARASMUS, PREMATURITY, ETC. 25.5 ■< <> 


ACUTE RESPIRATORY 18.5 " «• 


CONGENITAL MALFORMATION, ETC. 5.8 <« " 




ACUTE INFECTIOUS 5t4» << 




CONVULSIONS 3.4, " <• 




TUBERCULOSIS 2.0 >< <• 




SYPHILIS 1.2 <• 




ALL OTHERS 10.2 " 







Fig. 6. 



A wider diffusion of knowledge of infant-feeding and hygiene; a great 
improvement in the general milk s apply; the furnishing of pure, whole 
milk and of modified milk gratis, or at small cost, from milk depots; a 
general adoption during hot weather of some form of milk sterilization; 
the sending of a large number of infants into the country in summer; 
the closer supervision of infants in cities during the summer by visiting 
physicians and nurses, and the operation of many oilier agencies to im- 
prove sanitary eondil ions. Besides these important factors in preventing 
disease there must be considered the recent advances in pediatrics and 
the more, rational treatment of the sick infant by the average physician. 
During the second year the diseases of the gastro-intestinal tract are 
still a large factor in the death rate, also the acute diseases of the lungs 
and the acute infectious diseases, especially measles, diphtheria, and per- 



48 PECULIARITIES OF DISEASE IN CHILDREN 

tussis*. Deaths from scarlet fever are much less numerous. General 
tuberculosis and tuberculous meningitis are frequent. 

From the second to the fifth year the deaths are mainly from acute 
infectious diseases — chiefly diphtheria and scarlet fever — much less fre- 
quently from measles or pertussis. In the next group come the acute 
diseases of the lungs, general tuberculosis, and tuberculous meningitis. 

From the fifth to the fifteenth year the mortality in childhood is 
remarkably small, diphtheria and scarlet fever being still in the front 
rank in point of frequency. Next come the acute diseases of the lungs, 
meningitis, diseases of the bones, appendicitis, rheumatism, and cardiac 
disease. 

By far the largest single factor in reducing mortality after the first 
year is without doubt the use of diphtheria antitoxin. The serum treat- 
ment of cerebrospinal meningitis is important, but not influential in 
vital statistics, as cases are relatively infrequent. 

Sudden Death. — This is not a very uncommon occurrence in infants 
who are apparently healthy. They are sometimes found dead in bed 
under circumstances in which grave suspicion may unjustly rest upon 
the attendants. This usually happens with those who are delicate or 
suffering from malnutrition, especially in institutions where sudden 
death is by no means rare. The most frequent causes in infants are the 
following : 

1. Malformations. — While in most cases malformations of a serious 
nature give rise to symptoms, they may be absent, or may be so slight 
as to be overlooked. Infants may succumb during the first few days of 
life from malformations of the heart, lungs, kidneys, stomach or in- 
testines, and sometimes from diaphragmatic or umbilical hernia. 

2. Internal Hemorrhage. — This is chiefly limited to the first two 
weeks of life. In the cases that have come to our notice the cause has 
been rupture of some subperitoneal hemorrhage into the general abdomi- 
nal cavity, or meningeal hemorrhage. Such cases are reported in the 
chapter upon Visceral Hemorrhages in the Newly Born. Under these 
circumstances no symptoms may exist until the occurrence of collapse, 
with death in a few hours. 

3. Asphyxia from Overlying. — This is not common, except among 
the lower classes, and is most frequently due to intoxication on the part 
of the mother. Such infants after death present the usual lesions of 
death from asphyxia, but without any evidence of violence. It is not 
improbable that overlying has been held responsible for many deaths that 
were in reality due to other causes. 

4. Asphyxia from Aspiration of Food into the Larynx or Trachea. 
— This may be due to vomiting or to the regurgitation of food during 
sleep; in a very weak infant it may occur while awake. This is usually 



PROGXOSLS AND INFANT MORTALITY 40 

seen in infants who are less than a year old, and most of the reported 
cases have been under six months. Such children are usually delicate. 
There seems to have been vomiting with an attempt at crying, during 
which the food is drawn into the air passages. In some cases, as that 
reported by Demme, a single large curd of milk has been found in the 
larynx. In others, food is found in the larynx, trachea, and large bronchi. 
Cases have also been reported by Partridge and by Parrot, and we have 
met with at least three. The infants have generally been found dead in 
bed within a few hours after feeding. This accident is more likely to 
happen when an infant lies upon his back. 

5. Enlargement of the Thymus. — Although these cases are very im- 
perfectly understood, they are not rare. We see two or three each year. 
The condition is most frequent in infancy, but is not confined to this 
period. When a child is suffering from some minor illness, often bron- 
chitis, severe attacks of asphyxia may develop and sometimes convulsions 
may unexpectedly occur and death soon follow. Or the first attack may 
not be fatal. Sometimes sudden death follows the administration of an 
anesthetic, particularly chloroform. In most cases there is found besides 
an enlarged thymus, a general hyperplasia of the lymphatic tissues 
throughout the body known as status lymphaticus, more fully discussed 
elsewhere. 

(5. Atelectasis. — Tn very young infants there may be no symptoms 
noticed except those of general malnutrition until sudden death occurs, 
sometimes with convulsions and sometimes without any such symptoms. 
(See Atelectasis.) 

7. Marasmus. — In this class of cases sudden death is of very common 
occurrence. These children are often apparently as well two or three 
hours before death as for several weeks. Death frequently occurs at night, 
the children being found dead in bed in the morning. In some of the 
cases the exciting cause seems to be the lowering of the temperature, while 
in many no exciting cause can be found; the vital spark simply goes out 
after burning for some time with a feeble intensity. In some of these 
cases the autopsy reveals atelectasis, but in many cases nothing abnormal 
is found, death apparently resulting from heart failure. 

8. Convulsions in Children Previously Showing no Special Signs of 
Piscase. — Many of these cases are seen in children who were previously 
rachitic; some are associated with the status lymphaticus, and many are 
manifestations of tetany. The autopsy may show no lesion except cere- 
bral hyperemia. It is extremely rare for cerebral hemorrhage to produce 
death in this way. In some rachitic cases death is due to spasm of the 
glottis. 

!). Asphyxia in Older In funis and Young Children. — This may re- 
sult from the pressure of a retropharyngeal abscess upon the larynx or 



50 PECULIARITIES OF DISEASE IN CHILDREN 

trachea, or from the rupture of such an abscess into the air passages. 
Previous symptoms may have been wanting. Pressure upon the pneu- 
mogastric nerve leading to fatal asphyxia may be caused by tuberculous 
bronchial nodes, or by abscesses in the posterior mediastinum connected 
with caries of the spine. Sudden death may occur with spinal caries 
from dislocation of the upper cervical vertebrae. 

Sudden asphyxia may follow the ulceration of tuberculous lymph 
nodes and the escape of cheesy masses into the trachea or primary 
bronchi. This usually occurs in children from two to five years old. 

10. Death after a Few Hours' Illness, in which the Chief Symptom 
is High Temperature. — This is not an uncommon occurrence. Infants 
apparently well may be taken with great prostration and a high tempera- 
ture, which may rise rapidly to 106° or even 107° F., and death follow 
in from six to twelve hours, sometimes preceded by convulsions. These 
are often examples of acute septicemia, most frequently from the pneu- 
mococcus, sometimes from the streptococcus, or other organisms. In 
older children death may be due to malignant scarlet fever or epidemic 
meningitis; however, unless these diseases are prevailing epidemically, it 
is somewhat hazardous to make such a diagnosis. 

It does not fall within the scope of this chapter to consider such cases 
of sudden death as those which occur from heart failure after diphtheria, 
with pleurisy with effusion, or with myocarditis. These will be discussed 
elsewhere. 



PROPHYLAXIS 

There is no more promising field in medicine than the prevention of 
disease in childhood. The majority of the ailments from which children 
die it is within the power of man in great measure to prevent. Prophy- 
laxis should aim at the solution of two distinct problems: (1) The re- 
moval of the causes which interfere with the proper growth and de- 
velopment of children; (2) the prevention of infection. The former 
can come only through the education of the profession and of the 
general public, in the fundamental principles of infant feeding and 
hygiene. This is a department which has received altogether too small 
a place in medical education. The latter must come through the pro- 
fession and through legislation the purpose of which shall be more 
rigid quarantine, more thorough disinfection, and improved sanitation 
in all its departments. The subject of prophylaxis will be discussed in 
connection with the different diseases treated elsewhere. 



THERAPEUTICS 51 



THERAPEUTICS 



Therapeutics in infancy consists in something more than a graduated 
dosage of drugs. Many therapeutic means which are valuable in adults 
are useless in children, and many others which are of little value in 
adults are extremely useful in children. Children in the past have 
suffered much from overzealous treatment, particularly from drug- 
giving. In early life more than at any other period the old dictum 
non nocere should be heeded. It should be a fundamental principle 
never to give a dose of medicine without a clear and definite indication. 
If this rule is followed, it is surprising to find how often medication 
can be dispensed with. A second rule is equally important: never to 
give a nauseous dose when one that is palatable will answer the purpose 
equally well. The simpler prescriptions are made, the better. As a 
rule, infants revolt against most of the highly seasoned sirups and 
elixirs which are used to disguise the taste of unpleasant doses. Bitter 
medicines, when mixed with water, are frequently administered without 
difficulty. 

It is a common mistake to underestimate the importance of the 
hygienic surroundings of the patient, the value of good nursing, careful 
feeding, and judicious stimulation, just as it is to overestimate the 
beneficial effects of drugs. In the great majority of acute ailments not 
serious in character, for which a physician is called, the patient recovers 
quite as promptly without drugs as with them. This does not mean that 
such children require no treatment, but that the least important part of 
the treatment is drug-giving. In cases of severe illness, in infants 
especially, we must avoid all unnecessary medication, in order that the 
stomach may not be disturbed. Hence the importance of relying as far 
as possible upon local measures. The strong tendency to recovery from 
all acute processes, while seen in adult life, is even more striking in 
childhood, where, if we can but remove that which hampers the bodily 
functions, Nature will usually conduct the case to a satisfactory termi- 
nation. Thus, after an attack of bronchitis, it is often seen that the 
disturbance of the stomach and intestines can be directly traced to the 
drugs employed, and continues long after the original disease has sub- 
sided. In diseases of the stomach and intestines especially there is a 
great amount of unnecessary medication. In all chronic disturbances 
of nutrition — chronic indigestion, malnutrition, and anemia — no tonic 
is so good as a change of air and surroundings. 

Antipyretics. — The indications for the employment of antipyretics in 
children are somewhat different from those in adults. It is to be borne 
in mind that, where the cause is similar, all temperatures in children are ! 



52 PECULIARITIES OF DISEASE IN CHILDREN 

higher than in adults. Thus conditions, which in an adult would pro- 
duce a rise of temperature of only 100° or 101° F., in a child are not 
infrequently accompanied by a temperature of 104°, or even 105° F. The 
height of the temperature, as measured by the thermometer, is not to 
be taken as the only or even the best guide for the employment of anti- 
pyretics. The nervous disturbance which accompanies such a tempera- 
ture is much more important. The temperature may be 104°, or even 
105° F., and yet the child exhibit no signs of unusual discomfort. Such 
a temperature manifestly does not call for interference. High tem- 
perature from apparently trivial causes is very common. It is only a 
continuously high temperature or a recurring high temperature which 
indicates serious illness. Whenever the temperature is found to be much 
above the normal it should be carefully watched, but not interfered with 
until a diagnosis has been made, unless the symptoms urgently demand 
it; otherwise the physician may lose one of the most valuable aids to 
diagnosis, since it is not the height of the temperature but its course 
which is significant. In many cases it is very important to know whether 
the temperature uninfluenced by drugs is remittent, intermittent, or 
steadily high, and hence the advantage of waiting until a diagnosis 
has been made before disturbing the temperature curve. This is, of 
course, not admissible when the temperature is itself a source of real 
danger, which after all is seldom the case. Since the cause of a great 
many obscure temperatures is found in the stomach and intestines, it 
very often happens that a purgative, stomach-washing, or intestinal 
irrigation may be the most efficient antipyretic. In cases of moderate 
elevation of temperature we need go no further than cold sponging. 

The most reliable antipyretic measure for children is the use of cold. 
This may be employed — 

(1) As an Ice Cap to the Head. — In many cases of quite high tem- 
perature and restlessness in infants this alone will reduce the tem- 
perature one or two degrees and allay the nervous symptoms. 

(2) Cold Sponging. — For this purpose water at about 80° to 85° F., 
equal parts of alcohol and water, or equal parts of vinegar and water may 
be employed. In the case of infants, all the clothing except the diaper 
should be removed and the child laid upon a blanket. The body should 
be sponged for from ten to twenty minutes, and then wrapped in a 
blanket without further dressing. Cold sponging must be very frequently 
employed in order to be efficient in reducing high temperature. Its 
oreat value in allaying nervous symptoms, even when the temperature is 
not very high, is not sufficiently appreciated. Its effect is often more 
satisfactory than that of an anodyne. 

(3) Cold Pack. — The child should be stripped and laid upon a 
blanket. The entire trunk should then be enveloped in a small sheet 



THERAPEUTICS 53 

wrung from water at a temperature of 100° F. Upon the outside of 
this, ice may now be rubbed over the entire trunk, first in front and 
then behind. By this method there is no shock and no fright, and any 
ordinary temperature can usually be readily reduced. 

The rubbing with ice should be repeated in from five to thirty min- 
utes, after which the child may be rolled in the blanket upon which he 
is lying without the removal of the wet pack. The head should be\ 
sponged with cold water while this is being carried on, and artificial 
heat, if necessary, should be applied to the feet. The pack is continued 
from one to twenty-four hours, according to circumstances. 

(4) Cold Bath. — The child is put into a bath at a temperature of 
100° F., the temperature being gradually lowered by the addition of 
ice or cold water to 75° or 80° F. The body should be well rubbed while 
the child is in the bath and water should also be applied to the head. 
On removal from the bath, the body should be quickly dried and rolled in 
a warm blanket. The bath is usually continued from five to ten minutes. 

(5) Evaporation Bath. — The trunk is closely enveloped in two 
layers of surgeon's gauze, or some loosely woven equivalent, which is 
moistened from time to time with water at a temperature of 95° F., 
continuous evaporation being kept up by means of a hand, or better 
electric, fan. The evaporation bath would seem to possess some impor- 
tant advantages in the case of infants and young children, in that it is 
more efficient than sponging, involves little disturbance of the patient, 
and causes no shock or fright. Hot applications should constantly be 
made to the extremities. 

(G) Rectal Irrigations. — These are easily given, disturb the patient 
very little, and are effective in reducing the temperature. A double tube 
or two catheters may be employed. It is best to use at first water at a 
temperature of 90° F., and gradually reduce this to 70° F. The irriga- 
tion should be continued for ten or fifteen minutes, or even longer if the 
desired fall in temperature is not obtained, and may be repeated as often 
as every three hours. 

Antipyretic Drugs. — Except in cases of malaria, quinin should not 
be employed for the reduction of temperature in children. 

Of the many coal-tar derivatives employed, phenacetin lias the ad- 
vantage for children of being tasteless and causing little depression, but 
the slight disadvantage of practical insolubility. None of the drugs of 
this group is, however, to be employed in large doses with the sole pur- 
pose of reducing the temperature. Their great value in pediatrics con- 
sists rather in allaying the nervous symptoms which accompany fever, 
and this purpose can be accomplished by the use of comparatively small 
doses. To an infant of one year, phenacetin can he given in one-grain 
doses every hour or two hour.- until the desired e fieri is produced. For 



54 PECULIARITIES OF DISEASE IN CHILDREN 

a child of five years a dose of two grains may be given in the same man- 
ner. When used as indicated, these drugs are of very great value in 
making the patient more comfortable, in promoting sleep, and in allaying 
headache and general pains. In cases of hyperpyrexia they are, however, 
much less certain and less safe than the use of cold. 

Sedatives. — For most of the milder conditions where sedatives are 
required bromids are to be preferred. A preference should be given to 
the sodium salt. Young children require relatively large doses : e. g., in 
convulsive conditions five grains every two hours are often necessary at 
three months. Chloral is usually well borne even by quite young infants. 
Since it is often irritating to the stomach it may be advantageously given 
by the rectum. After rectal administration its effects are usually man- 
ifest in half an hour, and sometimes sooner. The rectal dose for an 
infant of one month is one grain; three months, two grains; one year, 
three to five grains. It may be repeated every two to four hours, accord- 
ing to indications. Doses by mouth should be about half as large. Other 
drugs may replace this in most diseases, but in the case of infantile con- 
vulsions nothing is so reliable as chloral. 

Belladonna is well borne by children, and in relatively larger doses 
than niost drugs. The eruption is more readily produced than the other 
physiological effects, and even quite small doses may be sufficient to bring 
out a very abundant blush. The parents should be advised of this fact, 
lest undue alarm be felt. 

The drugs classed as antipyretics — phenacetin and antipyrin — are 
exceedingly valuable in the treatment of many diseases of infancy where 
irritative nervous symptoms are prominent. In many cases they may 
advantageously take the place of opium except when pain is present. In 
all conditions where spasm is a prominent symptom, whether of the 
larynx or bronchi, or local or general convulsions, antipyrin is especially 
valuable. 

Stimulants. — Alcoholic stimulants are well tolerated even Ijy young 
infants; yet all stimulants, alcohol in particular, are very greatly abused 
in the hands of practitioners, and their indiscriminate and protracted use 
can not be too strongly condemned. 

The indications for the employment of stimulants are much the same 
in young children as in adults. In most of the acute fevers they are 
not to be given early in the disease, and in many cases they are not re- 
quired at all. They must often be used very sparingly while the tem- 
perature is high, but may be necessary as soon as it falls. In many acute 
febrile diseases stimulants are not called for at any period. 

The method of ad ministering alcohol is of no little importance. 
Brandy and whisky are in most cases to be preferred to the wines, but 
not always. For infants under one year old, brandy should be diluted 



THERAPEUTICS 



55 



with at least twenty parts of water. Altogether the best method of ad- 
ministration is to determine the amount to be given in every twenty-four 
hours, have it diluted sufficiently, and then administer it in small doses 
at short intervals. 

An infant one year old for whom alcohol is indicated should not be 
given to begin with more than one-fourth of an ounce of brandy or whisky 
during the twenty-four hours, and even in bad conditions it is rarely 
advisable to give more than twice this quantity, except for a very short 
period. In children four years old double the amount may be employed 
in the corresponding conditions. Little good and much harm is likely 
to follow such amounts as four or five ounces daily of brandy or whisky 
for children of two or three years. There certainly is a strong tendency 
at the present time to use less and less alcohol in therapeutics and many 
would abandon it altogether. 

Other stimulants, caffein, camphor, strychnin, digitalis, strophan- 
thus, etc., are used in children with much the same indications as in 
adults. Their application is more fully discussed in the different diseases 
in which they are employed. They may be used in the following doses 
at the different ages indicated: 



3 months. 


1 year. 


TTli 


m iii 


ni 


tti iii 


Gr. i 


Gr. i 


Gr. dr - 


Gr. 2^0 


TTl V 


ifl X 


m iii 


m vi 



5 years. 



Digitalis, tincture 

Strophanthus, tincture 

Caffein citrated 

Strychnin sulphate 

Camphor (10 per cent solution in oil) 
Epinephrin (1-1000 Sol.) 



TIL v 
Til V 

Gr. ii 
Gr. ^ 

TTI XX 

m x 



Note. — Camphor and epinephrin are for hypodermic use only. 

Tonics. — Cod-liver oil is particularly useful in the convalescence after 
acute diseases of the respiratory tract, in anemia, and with a large num- 
ber of children who are extremely delicate. In these patients it may be 
advantageously administered throughout the greater part of nearly every 
winter season. In convalescence after attacks of gastroenteric disease it 
should be withheld for a long time. When the tongue is coated, the 
digestion poor, and the stomach easily disturbed it should not be given 
at all. In the case of infants, as a rule, the pure oil is to be preferred to 
the emulsions. The administration of small doses — i. e., ten or twenty 
drops of the oil three times a day continued for a long period — is often 
better than the use of larger doses for a shorter time. 

Preparations of malt are sometimes of even greater value than cod- 
liver oil, for they can be used in many conditions when the oil is contra- 
indicated. The two may often be advantageously combined. 

The best preparations of iron for very young children are the bitter 



56 



PECULIARITIES OF DISEASE IN CHILDREN 



wine, sweet wine, saccharated carbonate, and the wine of the citrate. 
These are only slightly constipating, and many of them can be given with 
milk. Most of the organic preparations on the market are less reliable 
than those mentioned. For older children nothing is better than reduced 
iron or Bland's pills. 

Arsenic is second only to iron in the treatment of the anemia of chil- 
dren, and in very many cases it is to be preferred to iron. The tablet 
triturates of arsenious acid, one one-hundredth of a grain, may be given 
immediately after meals three times a day, or one or two drops of 
Fowler's solution largely diluted with water. 

Alcohol is useful in combination with some of the bitters, either small 
doses of quinin, nux vomica, or the bitter wine of iron. Usually wines, 
especially sherry, are to be preferred to spirits, although some children 
take spirits better. When combined with a bitter there is little danger of 
the formation of the alcoholic habit, even though its use may be long 
continued. 

Of the bitter tonics, nux vomica is easily superior to all others. 

Opiates. — Strong objections have been urged by many against the 
employment of opium in the diseases of infancy. While opiates have no 
doubt been abused, the fact remains that opium is almost as valuable a 
remedy in the treatment of disease during the first five years as at any 
other period of life. For infants relatively smaller doses are required 
than of most drugs. If the physician will accustom himself to the use 
of small doses, he will be surprised to see how satisfactory are the effects 
produced. 

The most useful preparations for young children are paregoric, 
Dover's powder, the deodorized tincture, morphin, and codein. The fol- 
lowing table gives what may be considered safe initial doses at the differ- 
ent ages : 



1 month. 



3 months. 



1 year. 



5 years. 



Paregoric 

Deodorized tincture 
Dover's powder 

Morphin 

Codein 



"I i 

Gr. A 
Gr. zU 
Gr. T b 



til n 

Gr. I 

Gr. T U 
Gr. T( Vo" 



"I v to x 

Gr. £ 
Gr. & 

Gr. A 



Til XXX tO Xl 

Ti t ii to iii 
Gr. ii to iii 
Gr. A 
Gr. T V to | 



Ordinarily doses like the above should not be repeated oftener than 
every two hours. In exceptional circumstances, as when very great pain 
is present, the dose may be given more frequently. In the hypodermic 
use of morphin it should be remembered that its effects are always more 
uniform and striking than when the drug is administered by the mouth, 
and the dose should therefore be smaller. In every instance where a full 



THERAPEUTICS 57 

dose of opium has been given the physician should wait until the effects 
have subsided before the dose is repeated. 

Drugs Well Borne by Children. — In this list may be mentioned 
belladonna, the bromids, the iodids, chloral, quinin, calomel — in fact, all 
mercurials — and opium also, though not all of its products. 

The drugs not well borne include particularly cocain and heroin. In 
the case of many others, while the constitutional effects are well tolerated, 
they must be given carefully to young infants, since they are irritants to 
the stomach. In this class may be mentioned the salicylates, salol, the 
astringent preparations of iron, and the acids. 

Vaccines. — These are suspensions of dead bacteria in a normal salt 
solution. Their application in pediatrics is confined to therapeutics; 
as a prophylactic measure they are seldom called for, except for the pre- 
vention of typhoid fever. Vaccine therapy has been employed in almost 
every form of bacterial infection. In the great majority of these the 
results have been disappointing. They are of unquestioned value in 
localized staphylococcus infections, particularly those of the skin, e. g., 
general furunculosis and larger multiple abscesses. In other staphylo- 
coccus infections they are sometimes useful, but results are very uncer- 
tain. In streptococcus infections whether localized or general their effect 
is doubtful; although in rare cases they have seemed to be of benefit. 
Pneumococcus infections are apparently not at all influenced by their use. 
Regarding the effect of vaccines on gonococcus infections of mucous mem- 
branes, one must speak very guardedly. The great majority of patients 
with gonococcus vaginitis so treated have received but temporary benefit, 
although a few striking cures have been obtained. Colon bacillus infec- 
tions of the urinary tract (pyelitis) sometimes appear to be decidedly 
improved by vaccines. With respect to most other conditions experience 
thus far does not warrant one in forming a sanguine opinion of their 
value. For the technic of vaccine treatment special works should be 
consulted. 

Counterirritants. — These are of great value in a large variety of dis- 
eases. 

The mustard paste is probably the most satisfactory means of pro- 
ducing quick counterirritation over a large surface. To make a mustard 
paste : Take one part powdered mustard and six parts of wheat flour, mix 
with lukewarm water, and spread between two layers of muslin. This 
should be removed as soon as a thorough redness of the skin has been 
produced — in most cases from five to eight minutes, according to the 
strength of the mustard employed. This may be repeated as often as 
every three hours, and continued for a week it necessary, without pro- 
ducing excoriations of the skin. For older children the paste may be 
made one part mustard to four parts flour. In pulmonary diseases it 



58 PECULIARITIES OF DISEASE IN CHILDREN 

should be large enough to surround the chest. When it is used to produce 
general reaction in heart failure it should cover the entire trunk. 

The Mustard Pack. — The child is stripped and laid upon a blanket, 
and the trunk is surrounded by a large towel or sheet saturated with 
mustard water. This is made as follows : One tablespoonf ul of mustard 
to one quart of tepid water. In this a towel is dipped, and while drip- 
ping wound around the entire body. The patient should then be rolled 
in the blanket. This pack may be continued for ten or fifteen minutes, 
at the end of which time there will usually be a very decided redness of 
the whole body. It may be repeated according to indications. Where it 
is desired to produce a general counterirritation, the mustard pack is not 
quite as efficient as the mustard bath, but it has the advantage in causing 
much less disturbance to the patient. The mustard pack is useful in the 
condition of collapse or of great prostration from any cause whatever, in 
convulsions, and in cerebral or pulmonary congestion. 

The turpentine stupe is made by wringing a piece of flannel out of 
water as hot as can be borne by the hand. Upon this is sprinkled ten or 
fifteen drops of the spirits of turpentine. The stupe is then applied to 
the body and covered with oiled silk or dry flannel. It is useful chiefly 
in abdominal pains or inflammations, but in infancy must be carefully 
watched or vesication will be produced. For frequent use it is not so 
valuable as the mustard paste. 

Stimulating liniments containing turpentine and other irritants are 
useful in inflammations of the chest, although less reliable than the mus- 
tard paste. One of the mildest and most useful preparations is camphor- 
ated oil. i\nother is olive oil four parts and turpentine one part. These 
may either be rubbed upon the surface, or a piece of flannel may be satu- 
rated with them and then applied to the skin. 

Local Blood-letting. — Leeches are sometimes useful in the early stages 
of acute inflammations of the mastoid or middle ear. They may also be 
applied to the precordium in acute pneumonia with signs of failure of 
the right heart, viz., great dyspnea and cyanosis. 

Dry cups may be used even in young infants, to relieve acute conges- 
tion in pneumonia or bronchitis, and for pulmonary edema. Wet cups 
should never be used for young children. 

Poultices are much too frequently employed and may with advantage 
be omitted in the treatment of most local inflammations. They have been 
largely replaced by wet dressings, especially those of aluminum acetate. 
In acute pulmonary inflammations their use is very limited. 

Cold. — Cold is useful in almost all forms of local inflammation. In 
inflammation of the cervical lymph glands and of the joints it is of 
undoubted value, but its advantage over heat is questionable. The effi- 
ciency of both cold and heat in these cases depends largely upon the 



THERAPEUTICS 59 

method of use. The difficulties in the way of their proper application are 
great in young children. Sometimes in pleurisy much greater relief is 
obtained from the use of an ice bag to the chest than from hot applica^ 
tions, but this is not the general experience. The treatment of pneu- 
monia by the application of the ice bag to the chest has many advocates, 
although in our hands it has not yielded the results claimed for it. 
It is admissible only in lobar pneumonia, and here chiefly in older and 
stronger children. The application of cold in young or very delicate 
children should be made with caution in all inflammations of the respira- 
tory tract. 

Cold is best applied to the head by an ice cap made like a helmet ; an 
ordinary rubber or flannel bag filled with ice may answer the purpose. 
The rubber coil filled with ice water is also an excellent method. For 
inflamed glands or joints the ice bag or the coil should be used; for the 
eyes, cold compresses, changed every minute. 

The Hot Pack. — All clothing is to be removed and the child's body 
covered with towels wrung from water at a temperature of from 100° to 
108° F., after which the body should be rolled in a thick blanket. These 
hot applications may be changed every twenty or thirty minutes until free 
perspiration is produced, which may be continued as long as necessary. 
This is mainly useful in uremia. 

The hot bath, like the mustard pack or the mustard bath, may be 
used to promote reaction in cases of shock or collapse. The patient should 
be put into the bath at a temperature of 100° F., the water being gradu- 
ally raised to 103°, or even to 106°, but not above this point. The body 
should be well rubbed while the patient is in the bath." A thermometer 
should be kept in the water to see that the temperature does not go too 
high. Unless this precaution is taken the danger of burning the child is 
great. During the bath, in most cases, cold should be applied to the 
head. 

The Hot-Air or Vapor Bath. — All the clothing should be removed 
and the patient laid upon the bed with the bedclothing raised above the 
body ten or twelve inches, and sustained by means of a wicker support. 
The bedclothing should be pinned tightly about the neck, so that only 
the head is outside. Beneath the bedclothing hot vapor is introduced 
from a croup kettle or a vaporizer. This will usually induce free per- 
spiration in fifteen or twenty minutes. It may be continued from twenty 
to thirty minutes at a time. Instead of vapor, hoi air may be intro- 
duced in the same way. The air space about the body is indispensable. 
The vapor bath is applicable chiefly to cases of uremia. 

The Mustard Bath. — Four or five tablespoonfuls of powdered mustard 
should be mixed for a few minutes with one gallon of tepid water. To 
this should be added four or five gallons of plain water at a temperature 



60 PECULIARITIES OF DISEASE IN CHILDREN 

of 100° F. Thi temperature of the bath may be raised by the addition of 
hot water to 103° or 106° F., if desired. Nothing is "more efficient than 
the hot mustard bath for a general derivative effect in bringing the blood 
to the surface in cases of shock, collapse, heart failure from any cause, or 
in sudden congestion of the lungs or brain. The bath should not usually 
be continued for more than ten minutes. If necessary, it may be repeated 
in an hour. 

The Bran Bath. — Put one quart of ordinary wheat bran in a bag made 
of coarse muslin or cheese cloth and place this in four or five gallons of 
water. The bran bag should be frequently squeezed and moved about 
until the bath water resembles a thin porridge. It may be of any tem- 
perature desired, but usually about 90° to 95° F. is best. A bran bath is 
of great value in cases of eczema, excoriations about the buttocks, or in 
other cases where the skin is very delicate, and plain water seems to 
irritate it. 

The tepid bath may be given at a temperature of 95° to 100° F. It 
is very useful in many conditions of excitement or extreme nervous irri- 
tability. To induce sleep it is often more efficient than drugs. 

The cold sponge or the shower bath should be given in the morning 
before breakfast, and in a warm room. The child should stand in a 
tub containing warm water enough to cover the feet, then a large 
sponge holding half a pint of water at a temperature of from 40° to 60° 
F. should be squeezed three or four times over the chest, shoulders, and 
spine of the child, the skin being rubbed meanwhile. The bath should 
not last more than half a minute. It should be followed by a brisk rub- 
bing until a thorough reaction is established. This is very useful at all 
ages, but it is a particularly valuable tonic in delicate children. It may 
be used in those only eighteen months old. Not the least of the beneficial 
results is the full expansion of the lungs from the strong cry which the 
bath usually excites. In younger infants a cold plunge may be substi- 
tuted. This should be merely a single dip of the entire body in water at 
a temperature of 50° to 60° F. In order that beneficial effects shall 
follow the cold plunge or cold sponging, a good reaction must be estab- 
lished. If children lack sufficient vitality to secure this, and if they 
remain pale, pinched and blue for some time after the bath, it must be 
discontinued altogether, or water of a higher temperature used. 

Nasal Spray. — This may be either of an aqueous or an oily solution. 
For the oil spray an atomizer should be employed. It is valuable in 
cases of dry catarrh, where there is a formation of crusts in the nose. 
A variety of oils may be used, benzoinol being perhaps as satisfactory 
as any. 

There are many forms of hand atomizers to be found in the market 
for the production of aqueous or oil sprays. For a cleansing nasal spray, 



THERAPEUTICS 61 

DobelPs solution, Seller's solution, or a two-per-cent solution of boric 
acid may be used. 

Nasal Irrigation. — In cases of considerable nasal obstruction and in 
the more serious affections of the rhinopharynx, only the syringe can be 
considered an efficient means of cleansing the cavity. 

The fountain syringe has the advantage of being easily regulated as 
to the force employed, this being determined by the height at which the 
bag is suspended above the bed. For ordinary purposes an elevation of 
one or two feet is sufficient, and rarely is a greater pressure than three 
feet advisable. The last is desirable when a thorough flushing of the 
rhinopharynx is required. The danger of forcing fluid into the middle 
ear is greatly lessened if the patient keeps the mouth wide open. 

Where a smaller amount of fluid is sufficient a piston syringe may be 
employed. This should be small enough to be easily worked with one 
hand. It should have a soft rubber tip, to prevent injuring the nasal 
mucous membrane, and the tip should be large enough to fill the nostril. 
The piston syringe for nasal use is made either of glass or hard rub- 
ber, and fulfils all the conditions mentioned. It is easy of action, can 
be readily cleansed, and holds about half an ounce. The same syringe 
should not be used for more than one patient, unless it has been very 
thoroughly disinfected. In hospitals, and even in private practice, nasal 
syringes are frequent carriers of infection. 

Either of two positions may be used in nasal syringing. In diph- 
theria, scarlet fever, or any constitutional disease attended by great 
depression, the child should not be removed from the bed. The syringing 
may be done by a single nurse, who stands at the head of the bed, alter- 
nately syringing the right and left nostril, turning the head from side 
to side. The other method is to hold the child erect on the lap, with the 
head inclined somewhat forward, the syringing being done by a second 
person standing behind. In either position the child's arms and hands 
should be securely pinioned to the sides by a sheet. To make sure that 
the rhinopharynx has been reached the water should return through the 
opposite nostril or the mouth. When properly done, no prostration and 
very little irritation are caused. The bulb (Davison) syringe should not 
be employed for nasal irrigation ; as the pressure can not be satisfactorily 
regulated, fluids are likely to be forced into the Eustachian tubes. 

Syringing the mouth and pharynx is useful in many pathological 
conditions of these parts, particularly in children too young to gargle. 
Either the fountain, piston, or bulb syringe may be used. If the pharynx 
is to be reached, the nozzle is used as a tongue depressor. This should 
be placed at the angle of the mouth between the back teeth. The child 
should lie upon the side or be held in the sitting posture, with the head 
inclined forward. Only bland solutions should be employed. 
4 



62 PECULIARITIES OF DISEASE IN CHILDREN 

Inhalations. — These are of very great utility in all affections of the 
respiratory tract. To be efficient, the patient should be put under a tent. 
A satisfactory tent may be made by erecting a T-shaped piece of wood at 
the head and foot of the crib and throwing over this a large sheet folded 
and pinned at the corners. Another method is to stretch a cord around 
the top of each of the four posts of the crib, or simply from the center 
of the head piece to the center of the foot piece ; the sheet should be used 
as in the first instance. A very good tent may be improvised by throwing 
a large sheet over an open umbrella. The better the tent the more satis- 
factory are the results. 

Inhalations may be in the form of vapor or spray. The apparatus 
employed may be the croup kettle, the vaporizer, or the steam atomizer. 
As all of these are used with alcohol lamps, innumerable accidents from 
fire have occurred with them. Patients and nurses should always be 
cautioned regarding this. Whenever possible, the electric heater should 
be substituted. The ordinary croup kettle is a clumsy affair and espe- 
cially likely to be the cause of accidents. 

There are various forms of apparatus for the purpose of obtaining 
medicated inhalations. 

Stomach-washing or gastric lavage consists in the introduction of 
water into the stomach through a flexible catheter or stomach tube and 
then siphoning it out. It is one of the most valuable therapeutic meas- 
ures we possess. The procedure is very simple, and may be considered 
entirely free from danger; in fact, it is difficult to pass the tube any- 
where else than into the esophagus. The amount of prostration produced 
by stomach-washing may be compared to that of an ordinary attack of 
vomiting. 

The apparatus for gastric lavage consists of a soft-rubber catheter, size 
lfi, American scale (24 French) — one with a large eye is preferred; a 
glass funnel, holding four to six ounces; two feet of rubber tubing, and a 
few inches of glass tubing to join this to the catheter. The child may be 
held in a sitting posture or placed upon the back ; the body should be well 
protected by a rubber sheet, with a large basin conveniently near. The 
catheter should be moistened. While the tongue is depressed with the 
forefinger of the left hand, the catheter is passed rapidly back into the 
pharynx and clown the esophagus. It is important that the first part of 
the introduction should be as rapid as possible, for if the child begins to 
gag from the pharyngeal irritation the introduction of the tube may be 
quite difficult. No resistance is ordinarily encountered after the tube 
reaches the esophagus. About ten inches of the catheter should be passed 
beyond the lips. When it has reached the stomach the funnel should he 
raised as high as possible, to allow the escape of gases almost invariably 
present. It should then be lowered, in order to siphon out the fluid con- 



THERAPEUTICS 63 

tents. If nothing escapes, the funnel is then to be raised and from two to 
six ounces of water poured into it from a pitcher; the funnel is then 
lowered and the water siphoned out. This procedure is repeated from 
four to ten times, or until the fluid comes back clear. About a quart of 
water is ordinarily used. Various solutions have been advised for stom- 
ach-washing, but nothing is better than boiled water, used at the tem- 
perature of from 100° to 110° F. — the higher temperature being em- 
ployed when the gastric irritation is very great. If mucus is present 
in the stomach an alkaline solution (bicarbonate of soda, 5j to Oj) is 
preferable. Through the tube are easily discharged mucus and small 
curds; larger ones are gradually broken down by repeated washing. 
Vomiting may be induced by overdistending the stomach with water. If 
there is great thirst there is often an advantage in leaving one or two 
ounces of water in the stomach. To this water it is at times beneficial to 
add lime water. 

Gastric lavage in its application is practically limited to children 
under two and a half years. It is easiest in those under eighteen months. 
Children of three years and over are usually so much alarmed and strug- 
gle so violently as to make it difficult and undesirable. 

The indications for lavage are: (1) Acute gastric indigestion, 
either with or without persistent vomiting. Here the purpose is sim- 
ply to clear the stomach of its irritating contents, and a single wash- 
ing may be sufficient. (2) Chronic indigestion attended by the produc- 
tion of gastric mucus. (3) Dilatation of the stomach. (4) Hypertrophic 
stenosis of the pylorus. (5) Poisoning. 

Gavage. — Gavage consists in the introduction of food into the stom- 
ach by a tube passed through the mouth. The same apparatus is em- 
ployed as in lavage, and the method is similar, with the exception that 
for gavage the child should be placed upon the back, the head being- 
steadied by an assistant. With older children a mouth-gag is often 
necessary. After the tube has entered the stomach the funnel should 
be raised to allow the gas to escape. The food is then poured into the 
funnel ; as soon as it has disappeared the tube is tightly pinched and 
quickly withdrawn, to prevent food from trickling into the pharynx, since 
this is often a cause of vomiting. If the food is regurgitated this usually 
happens at once. It may then be introduced a second time. After feed- 
ing, the child should be kept absolutely quiet upon the back. 

I n cases where all the food is given by gavage the interval between 
feedings must be considerably longer than under other circumstances. 
Sometimes the food given may be partially predigested, since digestion in 
these cases is usually feeble. The stomach should be washed before each 
feeding, in order to remove mucus and to be sure that it is empty before 
the meal is given. 



64 PECULIARITIES OF DISEASE IN CHILDREN 

Gavage is valuable in the feeding of premature infants and after cer- 
tain operations upon the mouth and neck. It is also useful, first, in the 
case of some very young infants, who, suffering from severe malnutrition, 
can not be induced to take food enough to sustain life ; secondly, in many 
acute diseases, particularly in septic cases where the child will not readily 
take the necessary food, as in diphtheria, scarlet fever, typhoid, pneu- 
monia, etc. ; thirdly, in many cases of cerebral disease where food is 
refused on account of delirium or coma; and, fourthly, in some cases 
of persistent vomiting. 

Gavage is a very simple procedure and one which a nurse can easily 
be taught. Not only may food be given, but also medicines and stimu- 
lants as may be required, with little or no trouble. The advantage of 
gavage over the continued coaxing or holding the nose and forcing the 
patient to swallow, will be at once apparent to one using it. 

Nasal Feeding. — The method is similar to gavage, the only difference 
being that the tube is passed through the nose, and consequently a much 
smaller one is used. No. 10 American or No. 16 French scale is a proper 
size. Nasal feeding is applicable to children over two years old, in whom 
the tube can seldom be passed through the mouth without the use of a 
gag, and then only after much struggling. It is of value after intubation, 
tracheotomy, and other operations about the throat, also in some cases of 
throat paralysis, especially after diphtheria. 

Irrigation of the Colon. — By irrigation of the colon is meant the 
flushing of the entire large intestine by fluids injected high up through 
a catheter or rectal tube. 

The apparatus required for irrigating the colon is a fountain syringe, 
five or six feet of rubber tubing, and a flexible rectal tube or soft-rubber 
catheter — No. 26 or 27, French scale, being preferred. Kemp's double- 
current tube of hard or flexible rubber is useful. The same result can 
be obtained by using two catheters, the larger for outflow, the smaller 
for inflow. The child is placed upon the back, with the thighs flexed 
and the buttocks brought to the edge of the bed or table. He should lie 
upon a Kelly pad or a rubber sheet so arranged as to form a trough 
emptying into a large basin or tub. The bag containing the water is 
hung two or three feet above the bed. If a catheter is used it is inserted 
just within the sphincter before the water is turned on. As it flows the 
catheter is gradually pushed upward. The water distending the intestine 
in advance of the catheter usually makes its introduction quite easy. In 
Fig. 7 is shown the colon of an infant of six months in position. It is 
the peculiar curve and the great length of the sigmoid flexure that make 
the introduction of water difficult, unless the tube is inserted for some 
distance. 

Usually a pint, and sometimes a quart, can be introduced before any 



THERAPEUTICS 65 

water returns. At least a gallon of water should be used for a single irri- 
gation. The washing should be continued until the water returns quite 
clean. Change of posture and gentle kneading of the abdomen should be 
employed during the irrigation, particularly the early part of it, to facili- 
tate the introduction of the water into the upper part of the colon. At the 
end of the irrigation the rubber tube is detached and the water allowed 
to escape through the catheter, which remains in situ. Sometimes as 
much as a pint of water remains in the intestine. This is usually passed 
within half an hour. As the irrigation of the colon almost invariably 
excites active peristalsis of the lower ileum, this part of the intestine is 
emptied as well. It is to be remem- 
bered that the colon of an infant six 
months old will hold about one pint 
without distention, and at the age of 
two years from two to three pints. 

Irrigation of the colon is useful 
to clear this part of the intestine of 
mucus, fecal matter, undigested food, 
and decomposing secretions. It may 
also be employed as a means of local 
medication in ileocolitis. Where the 
object is simply to cleanse the intes- 
tine, a saline solution — a teaspoonful 
of common salt to a pint of water — is 
preferred. 

The temperature of the water used 

for irrigation may be varied accord- Fig. 7.— Colon of a Child Six Months 
,-. • i • t i- tti Old, in Position. (From a photo- 

mg to the special indications. For graph.) 

ordinary purposes, where cleansing 

only is aimed at, a temperature of from 95° to 100° F. seems to be 

best, When the body temperature is high, or when there is much pain, 

tenesmus and straining, colder water has important advantages. 

Irrigation under most circumstances is required only once in twenty- 
four hours. It is important to use a large quantity of water. It must 
be done thoroughly to be of value, and either by the physician himself 
or an experienced nurse. 

In collapse or great prostration hot saline injections may be em- 
ployed for purposes of stimulation; the temperature of these should be 
from 105° to 110° F. 

Enemata. — Simple enemata are useful in infants and older children 
for constipation. When an immediate effect is desired the most efficient 
is one containing glycerin — e.g., for an infant, one teaspoonful to one 
ounce of water. Oil enemata (one-half to one ounce) are useful when 




66 PECULIARITIES OF DISEASE IN CHILDREN 

the fecal mass is hard and dry and expelled with difficulty. Enemata 
should always be given with care, and preferably a rubber catheter should 
be attached to the nozzle of the syringe. 

Nutrient enemata have a limited application in infancy, as the rectum 
soon becomes intolerant. The quantity injected should be small, rarely 
more than one or two ounces, and the interval between injections should 
be at least four hours. In older children they may be used as in adults. 
Glucose can be given in this manner when the stomach is intolerant. It 
is doubtful if other substances are sufficiently absorbed to be of much 
benefit. 

The administration of drugs per rectum is useful in certain cases 
when, on account of the unpleasant taste or vomiting, the administration 
by mouth is difficult — e. g., quinin and chloral. As a diluent, gruel is 
preferable to water. If quinin is used, the bisulphate is the best prepa- 
ration, but this must be well diluted. The temperature of enemata which 
are to be retained should be about 100° F. It is necessary in infancy to 
press the buttocks together for half an hour afterward to prevent the 
expulsion of the injection. 

Hypodermic Medication. — This is not so often used in young children 
as it should be, and is of the greatest service even in infancy. The use 
of morphin hypodermically in convulsions, of morphin and atropin in 
cholera infantum, of strychnin, camphor, caffein, epinephrin, or digitalis 
in circulatory failure, may be cited as examples. 

Hypodermoelysis. — This is a therapeutic measure of much value espe- 
cially in infants when great loss of fluid has been sustained, as, for in- 
stance, in severe diarrhea, or when fluids given by the mouth cannot bo 
retained as in pyloric stenosis. It is at times useful in cases of marasmus 
when the tissues are dry, shriveled and wasted. 

The solution employed is a normal saline (.9 per cent) prepared with 
sterile or preferably freshly distilled water. The amount injected may be 
from 100 to 120 c.c. (three or four ounces) to an infant of five or six 
pounds, and 150 to 250 c.c. (five to eight ounces) to one of nine or ten 
pounds. It is given once or twice in twenty-four hours. The fluid is 
contained in an inverted wash bottle suspended a foot or two above the 
patient and flows through a rubber tube and an ordinary hypodermic 
needle. The injection may be made into the subcutaneous tissue of any 
of the large areolar planes of the body, the back between the scapulae, or 
the abdomen being preferred. The apparatus should be sterilized before 
using. Before injecting, the solution should be warmed to body tem- 
perature and kept warm during injection by wrapping the bottle in flan- 
nel. It requires from one-half hour to two hours for the solution to 
flow into the tissues. Absorption usually takes place in four to six hours. 
Metabolism experiments have shown that a considerable part not only of 



THERAPEUTICS 67 

the water but of the salt so given is retained for two or three days by those 
whose tissues need it most. Healthy infants usually eliminate it very 
quickly, getting rid of most of it within twenty-four hours. A slight rise 
of temperature, rarely over 101.5°, occurs a few hours after the injection 
in about half the cases. Hypodermoclysis may often be repeated with 
advantage for several days. 

Massage. — In older children massage is useful for the same condi- 
tions as those for which it is employed in adults ; the most important are 
anemia, general malnutrition and chronic constipation. It is necessary 
that in the beginning only the mildest movements of massage should be 
employed, and these but for a short time. 

In infancy massage has a limited application and it is doubtful 
whether it really does more than can be accomplished by the general 
friction of the body. This rubbing, either with the bare hand or with 
cocoa butter, or with some form of fat, is useful in malnutrition, in 
rickets, and in wasting diseases when the circulation is feeble and the 
muscular tone low. Cocoa butter is cleanly and has a pleasant odor, and 
is. we think, quite as valuable as the more commonly employed cod-liver 
oil, which is exceedingly disagreeable. The inunctions should be given 
daily after the morning bath, before an open fire. The rubbing should 
be continued for fifteen to twenty minutes. 

Anesthetics. — As a general anesthetic for routine use, ether is to be 
recommended for children. Its disadvantages can largely be overcome 
by proper administration ; in point of safety it is immeasurably superior 
to chloroform for the very young. The administration of ether to young 
children may be advantageously preceded by a few whiffs of nitrous oxid 
or ethyl chlorid; both, however, are to be used with caution in infants. 
Ether should be given slowly, well diluted with air. and if used in this 
way its unpleasant features may be obviated. This can best be accom- 
plished by the use of some special form of inhaler. Ether should not be 
selected as the anesthetic for patients suffering from nephritis, bronchitis, 
pneumonia, pleurisy, or any other disease attended by obstructed respira- 
tion. 

The clangers from chloroform are greatest when it is given too rapidly 
or in too concentrated a form. Both are exceedingly likely to occur when 
it is administered to a struggling child. The greatest care and judgment 
should be exercised at such times, or disastrous consequences may follow. 
To produce and maintain the effect desired with the minimum amount of 
chloroform should always be the aim. All anesthetics, bin especially 
chloroform, are dangerous in children with the so-called lymphatic dia- 
thesis. For the removal of tonsils or adenoids, chloroform should not he 
employed. 

Xitrous oxid, while very useful in older children as in adults for 



68 PECULIARITIES OF DISEASE IN CHILDREN 

momentary operations, is not well borne by infants. It produces so early 
and so deep asphyxia that its prolonged use may be fraught with serious 
danger. 

Transfusion. — Two methods of performing transfusion are in use: 
The first, the end-to-end anastomosis introduced by Carrel, is somewhat 
difficult of technic and requires a skilled surgeon; second, the syringe 
method popularized by Lindemann, which is much simpler and can be 
done by one of very moderate experience. In this the blood is drawn from 
the vein of the donor, preferably a member of the family, into a paraffin- 
coated glass syringe and immediately injected into the vein of the child, 
usually the external jugular, but any available superficial vein may be 
chosen. In most cases it can be done without any dissection. As the 
blood must be rapidly passed from one person to another before coagula- 
tion takes place, at least one assistant and the use of four or five syringes 
are needed. The amount of blood usually injected into infants is from 
two to six ounces. 

The indications for transfusion are: first, in any acute hemorrhage, 
especially the hemorrhages of the newly born, where it is usually a specific 
remedy and acts at once ; secondly, in loss of blood during or after opera- 
tions. In some types of especially severe secondary anemia it is of benefit. 
In the slowly developing anemias, whether from disease of the blood- 
forming organs or as an accompaniment of malnutrition or marasmus, it 
is of very transient benefit. 



PART II 



SECTION I 
DISEASES OF THE NEWLY BORN 

CHAPTER I 
ASPHYXIA 

The lungs in the full-term fetus are of uniform dark red color, and 
show very distinctly upon their surface the lobular divisions. They are 
firm and solid and readily sink in water. The connective tissue is very 
abundant, and forms distinct fibrous septa, which stretch through the 
lungs in every direction. 

Inflation of the lungs begins with the first cry uttered by the infant 
as it is born into the world. The parts first expanded are the anterior 
borders of the lungs, then the upper lobes, and finally the lower lobes 
posteriorly. The superficial lobules are nearly always expanded before 
those in the interior of the lung. The inflation is sometimes irregular, 
because of the accumulation of mucus in some of the bronchial tubes. 
The right lung is frequently stated to be expanded earlier than the left. 
Although this is often the case, there is no uniformity in this respect. 
The important point to be remembered is, that the parts last inflated are 
the posterior portions of the lower lobes. The expansion of the lungs is 
a gradual process, and in healthy infants it is probably not complete 
for two or three days. In delicate children it may be postponed for 
several days, or even weeks. The above statements are based upon post 
mortem observations upon infants dying from various causes during the 
first weeks. It has often been a matter of great surprise to find at 
autopsy on an infant two or three days old, that less than one-half of 
the lung tissue was expanded, although the child had breathed well 
and shown no signs of atelectasis. Under normal conditions at full 
term inflation of the lungs takes place very readily, but not so readily 
in premature or delicate infants, on account of ,the feebleness of the 
respiratory muscles. The longer it is postponed after birth the more 

69 



70 DISEASES OF THE NEWLY BORN 

difficult does it become, on account of the changes which occur in the 
collapsed air vesicles. The condition of the child in utero may be de- 
scribed as one of fetal apnea, its oxygen being received and its carbon 
dioxid discharged through the placenta, which is essentially the organ of 
respiration at this period. This condition is interrupted by cutting off 
the supply of oxygen and the accumulation of carbon dioxid in the blood. 
Which of these is the important factor in inducing pulmonary respiration 
has been much debated ; but the best experimental evidence seems to show 
that it is the latter which stimulates the respiratory centers. 

Under the term "asphyxia" may be included all cases in which 
primary respiration is not spontaneously established with sufficient force 
to maintain life. Usually there is no attempt at pulmonary respiration 
until after the birth of the child, but it may occur in utero or at any 
stage of parturition. Asphyxia may be of intra-uterine or extra-uterine 
origin. 

Etiology. — 1. Intra-Uterine Asphyxia. — The maternal causes include 
any disturbance of the placental circulation during labor — anything 
which prolongs the second stage of labor, convulsions, hemorrhage, the 
use of ergot in the second stage, or, finally, the death of the mother. The 
causes relating to the child are pressure upon the cord, multiple winding 
of the cord about the neck, early separation of the placenta, and pressure 
upon the brain. If the respiratory stimulus comes before the birth of 
the child, the effort at respiration may cause the entrance into the mouth 
and air passages of amniotic fluid, mucus, blood, meconium, etc. 

2. Extra-Uterine Asphyxia. — This condition is a much less common 
one. It arises from causes quite apart from those above mentioned, and 
depends upon malformations or intra-uterine disease of the organs of 
respiration, circulation, or of the brain. It may be secondary to an injury 
of any of these organs received during parturition. It is also seen in 
premature infants, where it depends upon the feeble development of the 
nerve centers and respiratory muscles and upon the soft, yielding chest 
walls. 

Lesions. — In infants dying of intra-uterine asphyxia there are seen 
the usual changes found in death from suffocation, together with the 
effects of attempts at breathing in utero. There is general congestion of 
all the viscera, particularly of the brain and its meninges, the liver, and 
the lungs. They may show small, punctate hemorrhages, and occasion- 
ally large extravasations. Blood or bloody serum may be found in any 
of the serous cavities. The right heart is over distended with dark, soft 
clots, and the blood generally is more fluid than normal. The lungs may 
contain no air, but more frequently there are small, scattered areas in 
which lobular inflation has taken place. If the child has lived several 
hours there are larger areas of expanded lung, especially in the upper 



ASPHYXIA 71 

lobes, and these may even be emphysematous, if artificial inflation has 
been employed. In the month, nose, larynx, and even as far as the finest 
bronchi, there may be found aspirated materials — amniotic fluid, blood, 
mucus, or meconium. In extra-uterine asphyxia there may be organic 
changes in the viscera — malformations of the lungs or the heart, intra- 
uterine pneumonia or pleuritic effusion, malformation of the diaphragm 
and sometimes of the brain. 

Symptoms. — Under normal conditions the newly-born infant begins 
at once to scream and to use his limbs, the purplish color of the skin 
giving place in a few moments to a rosy pink. In the first degree of 
asphyxia — asphyxia livida — the child is deeply cyanosed. Either no 
attempt whatever is made at respiration, or it is superficial and repeated 
only at long intervals. The pulse is slow, full, and strong. The vessels 
of the cord are distended. Muscular tone is preserved, and also cutaneous 
irritability, so that with the application of almost any kind of external 
stimulus respiration is excited and the symptoms disappear. 

In the second degree — asphy.uid pallida — the picture is quite a differ- 
ent one. The face is pale and deathlike, though the lips may still be blue. 
The heart's action is weak, and by palpation can rarely be felt at all. By 
auscultation the sounds are feeble, irregular, and usually slow. The cord 
is soft, pale, and flaccid, and its vessels nearly empty. The sphincters 
are relaxed and meconium oozes from the anus. There is entire loss of 
tone in the voluntary muscles, so that the extremities and entire body 
seem perfectly limp. Cutaneous sensibility is abolished. The extrem- 
ities are often cold. There may occur a few short, convulsive contrac- 
tions of the respiratory muscles, but these are without effect and soon 
cease. Unless such cases receive the most prompt and efficient treatment, 
the heart's action becomes more and more feeble until it ceases and death 
occurs. Other cases are partly resuscitated and may survive for a few 
hours or days, when they gradually sink, respiration becoming more and 
more feeble in spite of all efforts to maintain it. Between these two 
extremes all degrees of severity are seen. 

In extra-uterine asphyxia there may be some attempts at voluntary 
respiration continuing for several hours, sometimes for a day or two, 
but this may be inadequate to sustain life. 

Diagnosis. — Almost the only condition with which asphyxia is likely 
to be confounded is cerebral compression from a meningeal hemorrhage. 
The difficulties in the case are much increased by the fact that the two 
conditions are not infrequently associated. It may then be impossible to 
tell that in addition to asphyxia, intracranial hemorrhage is present. If 
the hemorrhage is extensive and the asphyxia only moderate, ;i diagnosis 
is possible in most of the cases. In hemorrhage there is often ;i history 
of undue compression during delivery — sometimes the use of forceps. 



72 DISEASES OF THE NEWLY BORN 

The fontanel is bulging ; there is coma, and there ma} T be paralysis. The 
respiratory murmur may be quite strong for several hours, but it grad- 
ually fails as the child becomes completely comatose. Anemia resulting 
from a large hemorrhage, like that due to rupture of the cord, may simu- 
late the severe form of asphyxia. 

Prognosis. — This depends upon the grade of asphyxia and the treat- 
ment employed. There is but little tendency to spontaneous recovery in 
any form. In the milder cases recovery is almost invariable with any 
intelligent treatment. In the severest cases the outcome is always doubt- 
ful, although by persistent effort many infants that are apparently hope- 
less may be saved. In a prognosis as to the ultimate result, the frequent 
complication of asphyxia with meningeal hemorrhage should always be 
kept in mind. Apart from this complication it is doubtful whether 
asphyxia has anything to do with the production of idiocy. 

Treatment. — In every case the first step is to clear the mouth and 
pharynx of mucus by means of the finger covered with absorbent cotton. 
In the milder forms respiration is usually excited either by spanking the 
child or the alternate use of hot and cold baths. If the hot bath is 
employed, the water should be from 104° to 108° F. and always tested 
by a thermometer. After a moment the child should be dipped into very 
cold water, or the body may be douched with it. In the livid cases relief 
is often afforded by allowing the cord to bleed for a few moments before 
ligation. The loss of half an ounce of blood is ordinarily sufficient. 
Simply swinging the child in the air is a powerful stimulus to respira- 
tion. The above means will suffice in the great majority of cases. In 
the more severe forms, however, these are inadequate. There is no 
response whatever to external stimulation, either by heat or mechanical 
irritation. In these cases two methods of resuscitation may be employed : 
artificial respiration and direct inflation of the lungs. 

One of the most widely employed methods of inducing artificial 
respiration is that of Schultze. The infant is grasped by both axillae in 
such a way that the thumbs of the physician rest upon the anterior sur- 
face of the chest, the index fingers in the axillae, and the remaining 
fingers extending across the back. The child is thus suspended at arm's 
length between the knees of the physician, the feet downward and the 
face anterior. The body is now swung forward and upward, until the 
physician's arms are nearly horizontal. This produces the inspiratory 
effort. When this point is reached, an arrest in the swinging causes 
flexion of the trunk, the head now being directed downward, the lower 
extremities fall toward the physician until the whole weight of the body 
rests upon the thumbs. In this way expiration is produced. Lusk cau- 
tions against the employment of this method if the heart's action is very 
feeble, as it may cause the heart to stop altogether. This method should 



ASPHYXIA 73 

be used with care and skill; clumsy and too forcible manipulation has 
resulted in many serious injuries to the viscera and fractures of ribs or 
clavicles. 

A method introduced by Dew has been extensively employed in Xew 
York. The infant is grasped in such a way that the neck rests between 
the thumb and forefinger of the left hand, the head being allowed to 
fall far backward, the upper portion of the back resting upon the palm 
of the hand; with the right hand the knees are grasped between the 
thumb and fingers, the thighs resting against the palm of the hand. 
Inspiration is produced by depressing the pelvis and lower extremities, 
thus causing the abdominal organs to drag upon the diaphragm, and at 
the same time gently bending the dorsal region of the spine backward. 
In expiration the movement is reversed, the head being brought forward 
and flexed upon the thorax, while at the same time the thighs are flexed 
so as to bring them against the abdomen. The body is thus alternately 
folded upon itself and unfolded as the movements are carried on. If 
there is much mucus in the mouth, the movement of expiration should 
first be made with the body completely inverted. This method is simple, 
efficient, and much less fatiguing than that of Schultze when it is to be 
maintained for a long time. It is also of great advantage in that it can 
be carried on while the child is in the hot bath, one of the greatest objec- 
tions to the method of Schultze being the loss of animal heat incident 
to its use. 

In all cases where artificial respiration is used the first movement 
should be that of expiration, to expel, so far as possible, mucus or other 
foreign substances from the air passages. The movements should be 
made from eight to twelve times a minute, and not too forcibly, the child 
being kept in the hot bath between the movements, and as much as possi- 
ble during them. As long as the heart beats resuscitation is possible, 
and the case should not be abandoned. 

Direct inflation. of the lungs by the mouth-to-mouth method should 
not be employed. 

An ingenious apparatus for artificial inflation of the lungs has been 
devised by Carrel of the Rockefeller Institute, making use of Meltzer's 
method of the continuous insufflation of air. A flexible catheter contain- 
ing a wire stylet is introduced into the larynx. By means of a double 
bulb a continuous flow of air is maintained. A manometer measures the 
pressure employed and is a guide by which one is prevented from using 
an excessive amount of force. When the pressure employed is normal 
the mercury in the descending and ascending arms of the curved tube 
stands at about the same level; if an excessive amount of pressure is need, 
the mercury will be forced up into the bulb. Although this has been very 
little employed in infants ii has been extensively used in resuscitating 



74 DISEASES OF THE NEWLY BORN 

animals and seems to fulfill all the indications better than any apparatus 
hitherto suggested. It is so simple of construction that it can easily be 
put together by any instrument maker. 

The method introduced by Laborde, of making rhythmical traction 
upon the tongue ten or twelve times a minute as a means of exciting 
respiration, is sometimes very useful in conjunction with other methods. 
Faradization of the phrenic is of undoubted value, but somewhat difficult 
of application. 

In cases of asphyxia it is not enough to make the child cry. The 
deep respirations should be made to continue, for very often it happens 
that resuscitation is only partial, and that the child after six or eight 
hours lapses into its previous condition. All severe cases require close 
watching for the first twenty-four or thirty-six hours, as a repetition of 
the treatment is often necessary. 



CHAPTER II 
CONGENITAL ATELECTASIS 

This condition is one in which there is a persistence of the fetal state 
in the whole or in any part of the lung. 

Atelectasis is the pathological condition with which asphyxia of the 
newly born is usually associated. In most of the cases the condition of 
atelectasis is completely overcome by the means employed in resuscita- 
tion ; in some, however, these means are only partially successful, so that 
a portion of lung of variable extent remains in the fetal condition. These 
are the circumstances in which most of the cases of atelectasis arise. 
But there are others in which there is no history of early asphyxia, where 
the primary respirations, although taking place spontaneously, have not 
been of sufficient force and depth to produce full pulmonary expansion. 
This usually occurs in feeble infants, or in those who are premature. The 
causes of congenital atelectasis are therefore, in the main, those men- 
tioned as producing asphyxia. 

Lesions. — In cases where the child dies during the first few days the 
amount of expanded lung is often small, frequently not more than one 
fourth of the pulmonary area. The expanded portion is usually the 
anterior borders of the upper lobes. This is often the seat of acute 
emphysema. The rest of the lung is still in the fetal state; it is of a 
brownish-red color, very vascular, does not crepitate, and shows the 
lobular outlines both on the surface and on section. With a little force 1 
the atelectatic lung may be completely inflated. 



CONGENITAL ATELECTASIS 75 

If children have lived a longer time, nearly the whole of the upper 
lobes and the anterior portion of the lower lobes are usually well inflated. 
These portions are either normal or slightly emphysematous. The pos- 
terior portion of the upper lobes and the lower lobes are almost invariably 
the seat of the atelectasis. On the surface even these portions may pre- 
sent quite a large area of expanded vesicles, but the underlying portion 
may be solid to the touch, and crepitates but slightly. On section it is 
seen that only the most superficial part of the lung is inflated, while the 
interior of the lobe is unexpanded. Small hemorrhages are frequently 
seen beneath the pleura. 

It is usual for both lungs to be affected, and often, but by no means 
uniformly, to about the same degree. It is frequently a great surprise to 
discover that a child has lived for some weeks without presenting any 
signs of cyanosis, although using not more than one-third of his pul- 
monary area. This variety of atelectasis closely resembles the hypostatic 
pneumonia of delicate infants, and very often the two conditions are 
associated. It may require the microscope to decide between them. If 
congenital atelectasis has existed for a considerable time, there are usually 
found evidences of pneumonia. Inflation is not so easy as in recent cases, 
but with force the greater part of the lung can usually be expanded. The 
heart commonly shows the right auricle and ventricle to be distended with 
dark clots, and there is occasionally found a patent foramen ovale or 
some other form of congenital lesion. The liver and spleen are in most 
cases congested, and the spleen may be considerably enlarged. The 
mucous membrane of the stomach and intestines is sometimes deeply 
congested. 

Symptoms. — In one group of cases the children are asphyxiated at 
birth, but the attempts at resuscitation have been only partially success- 
ful. Although the patients may live for a few days, there is cyanosis, 
which gradually deepens, and death takes place from asphyxia, exhaus- 
tion, or convulsions. 

In a second group of cases the infants have been asphyxiated at birth, 
and resuscitated perhaps with difficulty, but to all appearance completely. 
They do not thrive, however, remaining small and delicate, gaining very 
little or not at all in weight, and showing poor circulation, cold extrem- 
ities, and occasionally subnormal temperature. It is characteristic of 
these cases that the cry is never loud, strong, and lusty. Some of them 
will not cry at all. Such children may live several weeks. There may 
develop at any time, often quite suddenly and without assignable cause, 
attacks of cyanosis with prostration. Children may have several such 
attacks, which do not excite suspicion since they pass away spontaneously. 
In other eases the symptoms are so severe that they may result fatally in 
a few hours, death being frequently preceded by convulsions. If ener- 



76 DISEASES OF THE NEWLY BORN 

getically treated the symptoms may pass away but, reappearing in a few 
hours, or again after a week or more, they gradually deepen in intensity 
until death occurs. 

Two cases that came under our observation in the New York Infant 
Asylum illustrate this point: The infants were twins, ten weeks old 
and delicate. Suddenly at night one child was taken with convulsions, 
became deeply cyanosed, and died in two and a half hours. He had been 
suffering from a slight attack of indigestion for a week previous. The 
other twin had been apparently well on the previous day. Two hours 
after the death of the first child the second was taken with similar symp- 
toms, dying in a few hours. At autopsy there was found very extensive 
atelectasis involving the posterior part of the upper and the greater part 
of both lower lobes. The lesions were almost identical in the two cases. 
In both, the stomach was greatly distended with food and gas. We have 
repeatedly seen the effect of overdistention of the stomach in producing 
cyanosis in young children, and in this instance we believe it to have been 
the exciting cause of the final symptoms. It was subsequently learned 
that during the six weeks of observation the nurse had witnessed several 
slight attacks of cyanosis in one of the infants. It is of course possible 
that the atelectasis in these cases may have been in part at least acquired. 

We have seen a number of cases, in which there was nothing whatever 
to attract attention to the lungs until the final attack of cyanosis oc- 
curred. In not all of these cases is there a history of asphyxia at birth. 
Some are only puny, delicate or premature, exhibiting during the early 
weeks of life all the signs of feeble vitality. The subsequent course is 
the same as in those in which there is early asphyxia. The duration of 
life in these cases depends chiefly upon the extent of the atelectasis. 

It is not to be, supposed that all cases of congenital atelectasis ter- 
minate fatally. Infants in whom there is every reason to believe that 
atelectasis exists, from the occasional attacks during the first few weeks 
of cyanosis, feeble cry, poor circulation, etc., may under favorable con- 
ditions with improved nutrition recover completely, even though no 
special treatment is directed to the lungs. 

Diagnosis. — The physical signs are of much less value than the symp- 
toms. It should be remembered that the principal seat of the disease 
is the lower lobes posteriorly. Percussion usually gives resonance over 
the entire chest, although this may be somewhat diminished posteriorly. 
There is not, however, so much change as one would expect to find, for 
the collapsed areas are surrounded by others which are overdistended, and 
there are in the midst of the collapsed parts, especially upon the surface, 
lobules which are inflated. If the two sides are involved to about the 
same degree, as is often the case, we can get no difference in the percus- 
sion note over the two lungs, and the change from the normal may be so 



ICTERUS 77 

slight as not to be appreciable. Where only one lung is affected a differ- 
ence can usually be made out. The respiratory murmur is rarely bron- 
chial, but generally only feeble in its intensity, and rather ruder in 
quality than normal. The cardiac sounds may be transmitted with 
abnormal intensity. As in the case of percussion, if only one lung is 
affected, this is of some value in diagnosis, but it is not sufficiently 
marked to be readily recognized when both sides are involved. Occa- 
sionally rales are present. 

Treatment. — In the newly-born child, whether asphyxiated or not, 
the physician should see to it that the infant not only cries, but does so 
loudly and strongly, and that this cry is repeated every day. If children 
do not cry naturally they must be made to do so by the alternate use of 
the hot and cold bath, as in cases of asphyxia, or by mechanical means, 
like spanking. This should be repeated at least twice a day, and con- 
tinued for from fifteen to thirty minutes. It may seem cruel but it is 
often the only means of saving life. Expansion of the lungs is much 
more easily induced during the first few days of life, becoming more and 
more difficult the longer it is delayed. Provided the condition is recog- 
nized, treatment is fairly successful. In institutions where delicate 
infants spend most of the time in their cribs, atelectasis is likely to be 
found. An infant needs exercise, and this is often only to be obtained by 
taking the child from its crib several times a day, by general friction, 
massage, the stimulus of fresh air, etc. Nothing is more certain to per- 
petuate atelectasis than to allow the infant a life of feeble vegetative 
existence. Food and feeding must be carefully attended to, but even 
these are of less importance than the maintenance of the animal heat. 
The temperature is often subnormal, and should be closely watched. If 
there is difficulty in keeping the child warm he should be rolled in cotton 
and surrounded by hot bottles, or kept in an incubator during the first 
few weeks. During attacks of cyanosis the same means are to be em- 
ployed as in cases of asphyxia of the newly born — cutaneous stimulation 
and artificial respiration — the administration of drugs being of little or 
no value, but oxygen may be of assistance. 



CHAPTER III 
ICTERUS 



Several varieties of icterus are met with in the newly born. 
1. It is often seen in the various forms of pyogenic infection. In 
such cases the icterus is usually mild. 



78 DISEASES OF THE NEWLY BORN 

2. It may be due to congenital malformations of the bile-ducts. 

3. It may depend upon interstitial hepatitis. 

4. The most frequent of all varieties is the so-called idiopathic 
icterus, sometimes spoken of as physiological icterus. 

In the cases included under the first head icterus is a minor symptom. 
The other varieties are sufficiently important to require separate con- 
sideration. 

Malformations of the Bile-ducts. — The common bile-duct is the most 
frequently affected. There may be atresia at the point where it opens 
into the intestine, the duct may be represented by a fibrous cord, or it 
may be absent altogether. In many cases this is the only lesion ; in others 
it is associated with an impervious hepatic or cystic duct; in still others 
the common duct is normal, but the cystic or hepatic ducts are imper- 
vious. 

At autopsy all the organs are usually found intensely jaundiced, par- 
ticularly the liver. In recent cases this is very much swollen, but pre- 
sents no marked organic changes. In cases which have lasted several 
months there is commonly found chronic interstitial hepatitis, sometimes 
to a very marked degree. This was present in nine of the fifty cases 
collected by Thomson. The gall-bladder is usually small, and often 
rudimentary. In cases of atresia of the common duct it may be greatly 
distended. 

The condition of the bile-ducts is ascribed to an error in development 
and subsequent catarrhal inflammation. There does not seem to be suffi- 
cient evidence to prove that hereditary syphilis is an etiological factor of 
much importance. This was present in but five of Thomson's cases. 

Symptoms. — The most striking symptom is jaundice, which is usually 
noticed a day or two after birth, and steadily increases until it becomes 
intense. The other symptoms of obstructive jaundice are present. The 
urine is colored a dark brown or bronze by bile pigment, the stools are 
white, and bile pigment is absent or present only in traces, except in 
cases where malformation is limited to the cystic duct. The liver as a 
rule is much enlarged. The spleen is often swollen. Hemorrhages 
beneath the skin or from any of the mucous membranes are quite com- 
mon. Vomiting is usually absent. In most cases there is progressive 
wasting, and death from inanition within the first few weeks. Of Thom- 
son's fifty cases, nine lived less than a month, and only eighteen over four 
months. Lotze has reported a case of a child living eight months with an 
impervious hepatic duct. A frequent cause of death in the more rapid 
cases is convulsions. 

These malformations cannot be influenced by any treatment. 

Interstitial Hepatitis. — There is seen in newly-born children a form 
of icterus which resembles the foregoing in many particulars, but which 



ICTERUS 79 

may end in recovery. In three such cases which have terminated fatally 
we have found the lesions of a general interstitial hepatitis, presumably 
of syphilitic origin. It is not certain that syphilis is always the cause of 
this condition, for the clinical history in some of them gives no evidence 
of this disease. While not a common condition we believe it to be more 
frequent than congenital malformations of the bile-ducts with which it is 
often confounded. 

The symptoms and course may be illustrated by the following cases : 
A full-term, well-developed child of eight pounds' weight became jaun- 
diced on the second day. By the fifth day the jaundice was intense; 
stools, pale yellow, and urine deeply bile-stained. Examination at three 
weeks showed both liver and spleen much enlarged. The jaundice was 
very marked for over a month ; it was nearly two months before it faded 
entirely. The nutrition of the child was a matter of much difficulty for 
several weeks. The enlargement of the spleen and liver like the jaundice 
disappeared very gradually. There was no other evidence of syphilis in 
this patient nor in the two other children of the family, and no history 
of this disease could be obtained in the parents. Yet the improvement 
which began with the use of mercurial inunctions strongly suggested a 
syphilitic lesion. 

In another case, the symptoms and course of which were almost 
identical, the stools, though nearly white, never failed to give the reac- 
tion for bile. A previous child in this family had died three years before 
at the age of six weeks with persistent jaundice, which had been diag- 
nosticated congenital malformation of the bile-duct. There was no his- 
tory of syphilis; but the mercurial inunctions seemed equally efficacious 
as in the first case cited. 

Xot much need be added to the symptoms described. In our cases 
which recovered and in the fatal cases there was no fever and no ascites ; 
but there was much tympanites.' The application of the Wassermann test 
will no doubt aid in clearing up the etiology of these cases. Other evi- 
dences of syphilis should always be carefully sought, but in all the cases 
we have seen, even those ending fatally and with syphilitic lesions at 
autopsy, clinical evidence of syphilis during life was wanting. A careful 
trial of antisyphilitic treatment should, therefore, be made in every case 
of protracted jaundice in a newly-born child. One should not be too 
ready to make the diagnosis of malformation of the bile-ducts and regard 
the case as hopeless. Xor does the fact that the child recovers without 
antisyphilitic treatment exclude syphilis as the cause, for one of Still's 
cases recovered from the jaundice and died at the age of nineteen months, 
the autopsy showing lesions evidently syphilitic 

Physiological or Idiopathic Icterus. — In 900 consecutive births at the 
Sloane Hospital for Women icterus was noted in •"><>(> cases. In 88 il was 



80 DISEASES OF THE NEWLY BORN 

intense, in 212 it was mild. According to the statistics of various lying- 
in hospitals of Germany, it was found in from 40 to 80 per cent of all 
infants. In the 300 cases just referred to, icterus was noticed on the 
first day in 4, on the second day in 19, on the third day in 72, on the 
fourth day in 86, on the fifth day in 67, and on or after the sixth day 
in 44. From the second to the fifth day is therefore the usual period for 
its appearance. 

It usually increases in severity for one or two days and then slowly 
disappears. The average duration in the mild cases is three or four days ; 
in those of moderate severity about a week; in the most severe cases it 
lasts many weeks. Icterus neonatorum is regularly found in premature 
and very delicate infants. The course with them is also more prolonged 
and the icterus usually more severe. 

The icterus is first noticed in the skin of the face and chest, then in 
the conjunctivae, then in the extremities. The skin varies in color from 
a pale to an intense yellow. The urine in most cases is normal. It some- 
times is of a light brown color, and only in the most severe cases does it 
contain bile pigment in appreciable amount. The stools are unchanged, 
the normal yellow evacuations occurring in the icteric as early as in 
those not affected. 

According to some observers, in infants who are icteric the initial 
loss in weight is greater and the subsequent gain slower than in other 
children. This is not borne out by the Sloane statistics. The proportion 
of icteric infants who did well, moderately and badly, was practically the 
same as of the other children in the institution not suffering from icterus. 
Icterus occurs with equal frequency in both sexes. There are usually no 
other symptoms than icterus, and the condition is practically never 
serious, though a prolonged course may occasion some concern. With the 
premature and poorly nourished it is the general condition and not the 
icterus that is dangerous. Very rarely a severe and fatal form of icterus 
is seen affecting successively several infants in a family. Death takes 
place in a few days without sufficient pathological evidence to explain the 
cause. 

In jaundiced infants who have died from accident or other causes the 
skin and almost all the internal organs are found icteric. There is stain- 
ing of the internal coat of the arteries, the endocardium, the pericardium 
and the pericardial fluid. The subcutaneous connective tissue is yellow; 
the spleen and kidneys only in the severe cases. The liver is slightly 
discolored. The bile ducts are normal. There may be small hemor- 
rhages, especially on the serous surfaces. The brain and cord are rarely, 
and the cerebrospinal fluid never, bile stained. 

Few subjects have given rise to wider speculation than this form of 
icterus. It has been held that it is due to obstruction from thick bile in 



ICTERUS 81 

the bile ducts, to extensive blood changes, and to various other 
causes. 

The researches of Yllpo have shown that in the last month of fetal 
life there is an increased production of bile pigment. Even at birth 
the blood contains three or four times the amount that the maternal blood 
contains. After birth there is a very rapid increase in the pigment 
content of the blood which usually lasts from three days to a week; ex- 
ceptionally for several weeks. At the end of a few days the blood may 
contain twenty times as much pigment as at birth. Usually after a 
few days the pigment in the blood diminishes, rapidly at first, then 
more slowly. The normal is not reached for several weeks. All infants 
show this increased amount of bile pigment. Those that subsequently 
develop icterus have at birth a greater bilirubin content in the blood 
and also produce more pigment subsequently. Icterus is noticeable 
when the blood contains, roughly, 125 mgm. of pigment to each 100 cc. 
of blood. The cause of the increased production of pigment is not en- 
tirely clear. There is not yet sufficient evidence that it is due to the 
destruction of the red blood cells. Only a slight amount of the pigment 
can be excreted by the kidney. It is most probable that the liver at 
this early stage of development is unable to remove the excess of pig- 
ment from the blood. This accumulates and when it reaches a certain 
concentration in the blood, causes appreciable icterus. With the cessa- 
tion of the blood destruction and the increase in functional activity of 
the liver, the pigment is removed. The difference in the icteric and the 
non-icteric infant is one only of degree. It is quite proper in such 
circumstances that the condition should be spoken of as "physiological 
icterus." 

Diagnosis of the Different Varieties of Icterus. — The diagnosis of 
physiological icterus is to be made from malformations of the bile- 
ducts, and interstitial hepatitis. In early sepsis it is doubtful if the 
infection produces the icterus. It is more likely that the two conditions 
arc associated. In the later sepsis jaundice may be due to an hepatic 
lesion, usually multiple abscesses. In malformations of the bile-ducts 
the icterus is usually more intense and appears almost immediately after 
birth; bile is absent from the stools; the icterus is persistent, and the 
symptoms go progressively from bad to worse, always ending fatally. 
In interstitial hepatitis the icterus develops at about the same time as, 
but is generally more marked than, in the physiological variety. Both 
liver and spleen are usually enlarged. The stools may be light colored, 
but still give a faint bile reaction. 

Physiological icterus requires no treatment. 



82 DISEASES OF THE NEWLY BORN 

CHAPTEE IV 

THE ACUTE INFECTIONS OF THE NEWLY BORN 

It is possible for the newly-born infant to suffer from almost any of 
the common infections diseases. Smallpox probably has been most fre- 
quently observed. Earely pertussis, influenza, measles, typhoid fever, 
malaria, and pneumonia have occurred in the first days of life. As the 
mothers in many instances were suffering from the diseases during or 
just prior to delivery, the infants appear to have been infected before 
birth through the circulation of the mother. In other cases, especially 
in pneumonia, influenza, and gastro-enteritis, infection may take place 
soon after birth. The symptoms of these diseases in the newly born 
differ very little from those occurring in any other young infant. In 
addition to the diseases mentioned, there are other forms of infection 
which belong especially — some of them exclusively — to the newly born. 

THE ACUTE PYOGENIC DISEASES 

Under this head are grouped various infections of the newly born, 
due to the entrance of the common pyogenic bacteria. They have been 
designated as puerperal fever of the child, also as pyemia or septicemia, 
or simply as sepsis of the newly born. A variety of pathological and 
clinical conditions are met with. In some cases there is only a localized 
external inflammation, often terminating in abscess formation; some- 
times one or more of the internal organs is affected; occasionally a 
general blood infection — a true septicemia — is seen without any note- 
worthy local lesion; finally, there are the cases attended by the pro- 
duction of multiple abscesses in the viscera, joints, or cellular tissue 
— a true pyemia. Formerly infections of this class were very com- 
mon, especially in large lying-in hospitals; but, owing to the general 
adoption of the methods of aseptic midwifery, they have steadily dimin- 
ished. 

Etiology. — The source of infection of the child may be the vaginal 
secretion of the mother or, in very rare cases, the mother's milk. Although 
it has been shown that in a great proportion of the cases the milk of a 
woman suffering from mastitis or from septicemia contains pyogenic 
germs, still the taking of these into the stomach is not likely to infect 
the infant. More frequently the child is infected by the nurse in the 
process of dressing the cord, bathing, or cleansing the mouth or eyes, 
possibly after having attended to the needs of a septic mother or another 



ACUTE PYOGENIC DISEASES 83 

child. Infection may be carried by the physician, by instruments, or by 
the dressings of the cord. Infection may occur through any wound or 
abrasion of the skin. 

Infection through the umbilicus may take place either before or after 
the separation of the cord. The infection may take place through the 
umbilicus, yet this may give no external evidence of disease, although 
the umbilical vessels inside the body may contain pus. From this focus 
of infection may arise peritonitis, meningitis, or other inflammations. 
Entering through the mouth, bacteria may lead to infectious processes 
in the throat, the stomach or intestines, and rapidly produce death; or 
the alimentary tract may be the focus from which infection of distant 
parts may arise. 

The microorganisms chiefly concerned in these infections are the 
common pyogenic bacteria, staphylococcus pyogenes aureus and the strep- 
tococcus. The next in importance is the gonococcus, the role of which, 
especially in cases accompanied by joint suppuration, has only recently 
been appreciated. Pneumococcus infections occasionally complicate the 
others mentioned. While streptococcus infections are in general more 
serious than those due to the staphylococcus, some of the most severe 
ones met with belong to the latter class. 

Clinical Varieties. — Omphalitis. — In this variety there is inflamma- 
tion of the umbilicus, and cellulitis of the abdominal wall in the im- 
mediate neighborhood. This results in the formation of an umbilical 
phlegmon. It may terminate in resolution, in abscess, or in gangrene. 
The usual termination is in abscess. These abscesses may be small and 
superficial, or they may be more deeply seated between the abdominal 
muscles and the peritoneum. Omphalitis usually begins in the second 
or third week of life, before the umbilicus has cicatrized. The process 
may result in erysipelatous inflammation and it may spread to the peri- 
toneum. 

Inflammation of the Umbilical Vessels. — This is one of the most 
frequent primary processes in pyemic infection. The umbilical arteries 
are more frequently involved than the vein. According to Eunge, in- 
flammation of the vessels is always preceded by inflammation of the 
connective tissue which surrounds them, as the poison is taken up by the 
lymphatics and not by the blood-vessels. Omphalitis is frequently pres- 
ent, but in some cases the umbilicus shows nothing abnormal. 

In arteritis the vessels may be involved to any degree: sometimes 
only a short distance from the abdominal wall, sometimes quite to the 
liver. They contain pus, and often septic thrombi. Saccular dilata- 
tion is frequently present at several points. Pus sometimes exudes from 
the umbilical stump on pressure. The other lesions accompanying 
arteritis are those of pyemic infection, more or less widely distributed. 



84 DISEASES OF THE NEWLY BORN 

There are frequently present peritonitis, suppuration of the joints, ery- 
sipelas, multiple abscesses of the cellular tissue, sometimes suppurative 
parotitis. Atelectasis is common. Pneumonia was found in twenty-two 
of Kunge's fifty-five cases. 

In cases of phlebitis, the umbilical vein is usually involved for its 
entire length from the abdominal wall to the liver. This may lead to 
an acute interstitial hepatitis going on to suppuration, or to phlebitis 
of the portal vein and some of its branches. In either case there is 
more or less parenchymatous hepatitis, and often multiple abscesses of 
the liver, most of the patients being jaundiced. Peritonitis also is a fre- 
quent complication. 

Peritonitis. — This is one of the most frequent pathological processes 
in pyemic infection, and is very often the cause of death. It is generally 
associated with umbilical arteritis, and often with erysipelas. In a 
considerable number of cases it is the most important lesion found. 
It may be localized or general. Localized peritonitis is generally in 
the neighborhood of the umbilicus or of the liver. It may result tin 
adhesions, or in the formation of peritoneal abscesses. More frequently 
the peritonitis is general and resembles the septic peritonitis of adults. 
There is a great outpouring of fibrin coating the intestines and other 
viscera and the inner surface of the abdominal wall, causing adhesions 
between the abdominal contents. Collections of sero-pus are found in 
the pelvis and in various pockets formed by the adhesions. Sometimes 
blood is present in the exudation. 

The special symptoms which indicate peritonitis are vomiting, ab- 
dominal tenderness and distention, and protrusion of the umbilicus. 
The abdominal enlargement is chiefly from gas, but may be partly from 
fluid. There are present thoracic respiration, dorsal decubitus, flexion 
of the thighs and fixation of all the muscles, the child lying perfectly 
quiet. The temperature is usually but not necessarily high. Marked 
leucocytosis is generally present. 

Pneumonia. — The most common form seen is pleuropneumonia. 
There is an abundant exudate of grayish-yellow fibrin covering the 
lung. Occasionally collections of pus are found in the sacs formed by 
the adhesions. Serous effusions are rare. The pulmonary lesion consists 
usually in a bronchopneumonia, with consolidation of larger or smaller 
areas in the lungs — more often in the upper than in the lower lobes. 
It is not uncommon for minute abscesses to be found in the lung at 
various points. There is a purulent bronchitis of the larger and smaller 
tubes. 

The symptoms are obscure and often indefinite. The only character- 
istic ones are cyanosis and rapid respiration, with recession of the chest 
walls on inspiration. The physical signs are inconstant and uncertain. 



ACUTE PYOGENIC DISEASES 85 

Pneumonia often can not be diagnosticated during life. In most of the 
fatal cases of pyogenic infection, whatever its type, there is found some 
involvement of the lungs. The changes are most extensive in cases in 
which the serous membranes are involved. 

Pericarditis is rare and usually associated with pleurisy. Endocar- 
ditis is very rare. Hirst has, however, reported a case. 

Meningitis. — When meningitis is present it is often associated with 
peritonitis or with pleurisy. The lesions are those of acute purulent 
meningitis with a copious exudation, sometimes associated with menin- 
geal hemorrhages, or with acute encephalitis and the production of 
multiple minute abscesses in the cortex. The local symptoms are often 
not marked, and are sometimes very obscure. The most characteristic 
are stupor, dilated pupils, opisthotonus, bulging fontanel, general rigid- 
ity, convulsions, and occasionally localized paralyses. The temperature 
is generally high. A positive diagnosis can generally be made by lumbar 
puncture, by which means also the exciting cause of the meningitis can 
usually be determined. 

G astro -enteritis. — Diarrhea is a frequent symptom in all septic cases, 
constipation being rarely present. In many instances vomiting is a 
prominent symptom. In a small proportion of cases the most important 
local lesions are in the intestines, generally in the nature of a superficial 
catarrhal inflammation. 

Stomatitis. — Infections of the oral mucous membranes are not in- 
frequent but sometimes very severe. They may be due to the strepto- 
coccus, staphylococcus aureus or the gonococcus. An occasional compli- 
cation of oral infections is abscess of the parotid. 

Osteomyelitis. — Allard has reported a series of cases in which, after 
the general and local symptoms of pyogenic infection had existed for 
some time, suppuration occurred over various bones, especially the 
humerus, tibia, metatarsal bones, sacrum, etc. Trephining revealed the 
lesions of osteomyelitis. The abscesses usually made their appearance 
between the fourth and the sixth week. The most rapid case terminated 
fatally on the fourteenth day, and none lasted more than two and a half 
months. 

Joint Suppuration. — In certain pyemic cases, and in some in which 
there are no other symptoms, 'acute suppuration in the joints occurs. 
This may come on very acutely in the first or second week, or more 
slowly as late as the second or third month. In the acute cases it is 
exceptional to have but one joint involved; frequently there are four or 
five. The small joints are rather oftener affected than the large ones, 
but almost any articulation in the body may be involved. With multi- 
ple joint suppuration there are present the general symptoms of pyemia 
— high temperature, marked prostration, wasting, and usually secondary 



86 DISEASES OF THE NEWLY BORN 

visceral inflammations develop. In those which occur late, or which 
develop more slowly, fewer joints are involved, often but a single one, 
the febrile symptoms are less marked or wanting. In our own experience, 
the organism most frequently found in these cases is the gonococcus; 
next to this in importance is the streptococcus and occasionally the 
pneumococcus is found. The joint lesion is usually a superficial one, 
the bones generally escaping. The gonococcus cases probably occur most 
frequently as a complication of ophthalmia ; but we have seen several in 
which ophthalmia was not present and where the point of entry could 
not be determined. 

Many of the abscesses supposed to be in the joints are shown at opera- 
tion to be at the epiphyses; from this source the joints may be involved 
secondarily. A point to be remembered in the diagnosis of these joint 
inflammations is their resemblance to the epiphysitis of hereditary syph- 
ilis and other symptoms of that disease should be looked for. The con- 
fusion is increased by the fact that in syphilitic cases abscesses may 
follow as a consequence of a secondary infection. 

Abscesses in the Cellular Tissue. — These are quite frequent, and may 
occur with suppuration in the joints or the internal organs, or they may 
exist as the only lesion. They are nearly always multiple and may be 
found in almost any location. They vary in size from one containing 
a few drops to half an ounce of pus. They are due to the introduction 
of pyogenic germs, usually staphylococci. Their course is benign, and 
they require no treatment except incision and cleanliness. When there 
is a disposition to their continued formation, the skin should be washed 
with an antiseptic solution and vaccines should be administered. 

Erysipelas: — This is seen especially during the first two weeks of 
life and usually starts from the umbilicus or some abrasion of the skin, 
most frequently about the genitals or the scalp. When originating at 
the umbilicus it is generally complicated by other lesions, such as peri- 
tonitis and umbilical phlebitis. If it starts from any other part of the 
body it may be uncomplicated. Erysipelas beginning at the umbilicus 
gives rise to an area of induration and a circumscribed erythema. At 
first it may resemble a simple cellulitis ; but the steadily increasing area 
of elevated induration and redness soon indicates the nature of the in- 
flammation. From whatever point starting, the erysipelatous inflam- 
mation, owing to the feeble resistance of the tissues, in most cases 
spreads widely. The entire abdomen, chest, and back may be involved, 
and it may even spread to the extremities. Nearly the whole trunk may 
be affected in four or five days. It usually involves only the skin and 
superficial cellular tissue; but it may involve the deeper areolar planes 
and terminate in diffuse suppuration, or even in gangrene. 

The constitutional symptoms are severe: great prostration, continu- 



ACUTE PYOGENIC DISEASES 87 

ously high temperature — 102° to 105° F. — rapid wasting, and frequently 
vomiting, diarrhea, or convulsions are present. The disease is always 
serious, and usually fatal. It is often complicated by bronchopneu- 
monia. General edema of the affected parts may persist for a few weeks 
after the inflammation subsides. 

Distribution of the Lesions, — The frequency of the different visceral 
lesions in eighty-seven autopsies published by Bednar was as follows: 
Peritonitis in twenty-nine, pneumonia in fifteen, pleurisy in ten, menin- 
gitis in nine, meningeal hemorrhage in eight, encephalitis in eight, cere- 
bral hemorrhage in four, enterocolitis in five, pericarditis in four. In 
thirty-one cases there was umbilical arteritis, and in nine cases umbilical 
phlebitis. There was one case each of pulmonary hemorrhage, pleural 
hemorrhage, acute hydrocephalus, acute bronchitis, and suppuration in 
the cellular tissue. Eunge's later observations of thirty-six cases showed 
umbilical arteritis in thirty, umbilical phlebitis in three, and normal 
umbilicus in three. He found pneumonia in twenty-two of fifty-five 
cases. Other lesions frequently associated are atelectasis, swelling and 
softening of the spleen, cloudy swelling of the liver and kidneys, occa- 
sionally with foci of suppuration in these organs. 

General Symptoms. — These may begin at any time during the first 
ten days — very rarely after the twelfth day. Fever is an exceedingly 
variable symptom — it may be very high; it may be almost absent; oc- 
casionally there is subnormal temperature. The course of the tempera- 
ture is very irregular. Wasting is constant and quite rapid. It depends 
upon the inability to take and digest food, upon the intestinal complica- 
tions, and upon infection. In quite a number of cases wasting is almost 
the only symptom. Icterus is common; in many of the worst cases it 
is intense. It is met with where the liver is the seat of an acute paren- 
chymatous or acute suppurative inflammation, and in many other cases 
where it depends apparently upon the blood changes. Hemorrhages 
are common, and may be the direct cause of death. They may come 
from the umbilicus, the intestine, or almost any mucous membrane. 
They are sometimes subcutaneous, causing a general hemorrhagic erup- 
tion. Nervous symptoms are generally present, and are sometimes 
marked. They are restlessness, rolling of the head, a constant whining 
cry, twitchings of the muscles of the extremities or face, stiffening of 
the body, more rarely general convulsions. Late in the disease, dulness 
and stupor are present. The pulse is rapid and weak and the respirations 
are often irregular, even when there is no cerebral complication. Diar- 
rhea is frequent; the stools are green, brown, sometimes black from 
the presence of blood, and are often very foul. Vomiting is less com- 
mon. In addition to these there are symptoms due to the various forms 
of local inflammation — peritonitis, meningitis, pneumonia, erysipelas, 



88 DISEASES OF THE NEWLY BORN 

subcutaneous suppuration and gangrene, these all being found in vary- 
ing degrees and in various combinations. 

Prophylaxis. — Pyogenic infection of the child, like puerperal fever in 
the mother, may be considered a preventable disease. Its occurrence is 
usually due to a failure to carry out proper rules regarding cleanliness 
and asepsis in connection with delivery. The statistics of the Moscow 
Lying-in Asylum, published by Miller in 1888, show that previous to 
the general . introduction of aseptic methods, from six to eight per cent 
of all infants born in the institution died from some variety of infection. 
In twenty-three hundred successive labors at the Sloane Hospital for 
Women, covering about eight years, not a single marked case occurred. 
From these figures it will be evident that in the vast majority of cases 
the occurrence of a case of infection of a serious nature is the fault of 
the physician or nurse in attendance. 

The umbilicus should be cleansed and treated like any other fresh 
wound. Dry dressing should invariably be employed, and sterilized 
gauze or salicylated cotton in preference to household linen. If suppu- 
ration occurs at the time the cord separates, the parts should be cleansed 
daily with a bichlorid solution, and a wet dressing of the same applied. 
The ligatures and everything which comes in contact with the umbilical 
wound should be sterilized. Careful attention should be given to the 
mouth, genitals, and all the mucocutaneous surfaces, to prevent excoria- 
tions and intertrigo. Finally, every septic case occurring in an insti- 
tution should be immediately isolated. A nurse in charge of a septic 
mother should not have the care of the infant. 

Prognosis. — Pyogenic infections in the newly born, even in their 
mildest forms, are serious, and in their most severe forms almost always 
fatal. Very few cases recover in which erysipelas or any important 
visceral inflammation is present. The resistance of these patients is so 
feeble that the tendency of every inflammation is to spread, until they 
die from exhaustion. Only patients with localized inflammations, such 
as those of joints, skin, etc., are likely to get well. 

Treatment. — This practically resolves itself into the treatment of in- 
dividual symptoms as they arise. Wherever suppuration occurs, external 
abscesses should be evacuated and treated antiseptically. For the local 
inflammations of the lungs, peritoneum, and brain, little or nothing can 
be done in the way of direct treatment. Such inflammations are to be 
prevented, but can seldom be cured. The general indications are to look 
closely to the child's general nutrition by careful attention to all details 
of nursing and feeding, using stimulants whenever required by the con- 
dition of the circulation. For a local application in erysipelas, nothing in 
our experience has proven better than ichthyol ointment, ten to twenty- 
five per cent strength. It should be applied daily, spread upon muslin, 



OPHTHALMIA 89 

which is then covered by gutta-percha tissue to prevent drying. Vac- 
cines have been much employed in erysipelas; our own experience, how- 
ever, coincides with that of most observers that there is very little evi- 
dence that they have any value. 

OPHTHALMIA 

Ophthalmia of the newly born is to be classed among the pyogenic 
diseases. It usually consists in a purulent conjunctivitis. In the more 
severe cases there may be ulceration of the cornea, and even perforation 
into the anterior chamber of the eye. 

The highly infectious nature of this ophthalmia is established. In 
the most severe cases the microorganism generally found has been the 
gonococcus ; but in the milder forms the gonococcus may be absent, and 
any of the common pyogenic germs may be found. In the gonococcus 
cases the infection occurs during labor, from the secretions of the 
mother, from the examining fingers of the physician, or from instru- 
ments; or after birth from infected cloths and other materials which 
come in contact with the eye. Healthy lochia produce only a catarrhal 
inflammation. The infection occurring after birth may take place at 
any time. That due to gonococcus infection from the mother is gen- 
erally manifested on the third day, and is often virulent from the outset. 

The symptoms are, swelling of the lids, chemosis, copious purulent 
discharge, sometimes hemorrhages from the lids, ulceration, and there 
may even be sloughing of the cornea. The course of the disease depends 
upon the cause and upon the treatment employed. In the cases not 
due to the gonococcus the course is generally benign, and with ordinary 
cleanliness usually ends in recovery without any permanent damage 
to the sight. The gonococcus cases, unless energetically treated from 
the outset, are very frequently followed by permanent loss of vision. The 
best statistics upon the causes of blindness in adults show that from 
twenty-five to thirty per cent. of such cases are due to ophthalmia in 
the newly born. This disease is occasionally complicated by other symp- 
toms of gonococcus infection of a pyemic nature. Many cases followed 
by acute articular symptoms have been observed. 

Prophylaxis is of the utmost importance. Crede's statistics show that 
in 1874: the frequency of ophthalmia in his lying-in hospital was 13.0 
per cent. In the three years ending 1883, among 1,160 newly-born 
children, only one or two cases occurred. The method of prophylaxis 
which he adopted consists in dropping into the eyes of every child, im- 
mediately after birth, one or two drops of a two-per-ccnt solution of 
nitrate of silver. The general adoption of Credo's method, or of some 
similar means of disinfection, has resulted in a very great diminution in 



90 DISEASES OF THE NEWLY BORN 

the frequency of ophthalmia throughout the world. Tliese prophylactic 
means should be obligatory in all institutions, and should be used in 
all cases in private practice wherever there is any possible suspicion of 
the existence of gonorrhea - In all other cases the eyes should be care- 
fully cleansed with a ten-per-cent solution of argyrol. The use before 
delivery of an antiseptic vaginal douche is theoretically indicated, but 
practically it has been found to be inadequate for the prevention of the 
disease. 

Treatment. — Everything which comes in contact with the eyes should 
be carefully disinfected. All cloths, cotton, etc., used for cleansing 
should be immediately burned. . The strictest antiseptic precautions 
should be insisted on to prevent the spread of the infection by nurses. 
In institutions containing infants, severe cases of ophthalmia should 
always be isolated. The most important thing is to keep the eyes clean. 
In severe cases they must be cleansed every twenty minutes, night and 
clay. It may be done by irrigation, or by using an eye-dropper with a 
bulbous tip, inserted alternately at the inner and the outer angle of 
the eye, and the fluid injected with force sufficient to empty thoroughly 
the conjunctival sac. Either a saturated solution of boric acid, or a 
1-5,000 solution of bichlorid, may be used in this way. Once or twice 
in twenty-four hours two or three drops of a ten-per-cent solution of 
argyrol should be used in each eye after cleansing with sterile water. 
Next to these measures is the use of cold. It may be applied as ice 
compresses which are changed every minute or two from a block of ice 
to the eye. These may be continued one-fourth of the time* in the milder 
cases ; in the severe ones almost constantly. When the cornea is involved 
the pupil should be dilated by atropin. If only one eye is affected the 
sound one should be protected by covering it with a compress kept wet 
with an antiseptic solution. 

TETANUS 

Tetanus is an acute infectious disease characterized by tonic muscular 
spasm, which increases in severity by paroxysms occurring at longer or 
shorter intervals. It may be limited to the muscles of the jaw (trismus), 
or may affect all the muscles of the trunk, extremities, and neck. 

The germ of tetanus usually gains access to the body of the infant 
through the umbilical wound. It exists in the soil, and the disease 
prevails endemically in certain localities. It is common in certain parts 
of Long Island and New Jersey. Among the negroes in some parts of 
the South it has for many years occurred with great frequency. It is 
stated that on one of the islands of the Hebrides every fourth or fifth 
child dies of tetanus. In a single house in Copenhagen eighteen cases 



TETANUS 91 

were observed. Tetanus presents no essential lesions. It is rare except 
where dirt and filth prevail; but these alone are not sufficient to produce 
the disease. It is rare in the tenements of New York. 

Symptoms. — These, as a rule, begin on the' fifth or sixth day, or at 
the time of the separation of the cord. The first symptoms may not 
appear until the tenth or twelfth day, but rarely later than this. Gen- 
erally the first thing noticed is difficulty in nursing, which on examina- 
tion is found to be due to rigidity of the jaws (trismus). Nursing may 
be impossible on this account. The muscles of the jaw feel hard, the lips 
pout, and all the muscles of the face seem firm. Soon a slight stiffening 
of the body occurs, the child straightening the back as he lies upon the 
lap and continuing rigid for a moment or two. In the interval he is at 
first completely relaxed. These paroxysms soon increase in frequency 
until they may come on every few minutes, being excited by any move- 
ment of the body. The relaxation is then only partial, and the neck and 
extremities and sometimes nearly the whole body may become rigid and 
stiff as a piece of w T ood. The arms are extended, the thumbs adducted, 
and the hands clenched. The thighs and legs are extended, and no 
motion is possible at the hip or knee. The jaws can be separated slightly 
or not at all. The firm contractions of the facial muscles give a peculiar 
expression to the features. There is a low, whining cry. Swallowing is 
difficult, sometimes impossible. The pulse is rapid and soon becomes 
weak. The temperature at first is normal, but in the most acute cases 
rises rapidly to 1Q4° or even 106° F. ; in the milder cases it does not 
go above 101° F. 

Death may be due to exhaustion, to fixation of the respiratory muscles, 
or to spasm of the larynx. In the less severe cases all the symptoms are 
milder, and there may be intervals in which the rigidity is scarcely no- 
ticeable, so that respiration and deglutition may be carried on for some 
time. In cases which terminate in recovery the temperature is but 
slightly elevated. The tonic contractions gradually become less severe, 
and the paroxysms less frequent. The children usually suffer for sev- 
eral weeks from the general symptoms of malnutrition, which are pro- 
portionate to the severity of the attack. Of eighty-eight fatal cases 
which are reported by Stadtfeldt all but five died between the ages of 
six and ten days. The duration of the disease in the fatal cases is seldom 
more than forty-eight hours, often less than twenty-four hours; in 
those terminating in recovery, between one and three weeks. 

Prognosis. — Few diseases of infancy are more fatal than tetanus. 
Where it prevails endemically it is regarded by the laity as so uniformly 
fatal that usually no physician is called. Scattered through medical lit- 
erature are quite a large number of isolated cases in which recovery has 
occurred. At the present time the proportion of fatal cases is probably 



92 DISEASES OF THE NEWLY BOKN 

between ninety and ninety-five per cent. Sporadic cases more frequently 
recover than those occurring in districts where the disease is endemic. 
The later the development of the symptoms, the slower their course, and 
the lower the temperature, the more likely is the case to recover. 

Prophylaxis. — A proper understanding of the nature of the disease 
has brought with it the means of rational prevention. The first essen- 
tial is obstetrical cleanliness, which must include scissors, hands, dress- 
ings, ligatures — in short, everything which comes in contact with the 
umbilical wound. In districts where tetanus is endemic, thorough asep- 
tic treatment of the umbilicus should be insisted upon, both at the first 
dressing and later, particularly at the time of the separation of the cord. 

Treatment. — All drugs whose physiological action is that of motor 
depressants of the spinal cord have a certain amount of value in tetanus. 
The most important ones are chloral and the bromids. Nearly all the 
reported cures have been by one of these drugs or a combination of 
them. The mistake usually made is in using too small doses. Enough 
to produce the physiological effects of the drug must be given. The 
initial dose should not be large, but it should be repeated until the full 
effects are obtained. Chloral, however, has been the drug most gen- 
erally relied upon. An hourly dose of one or two grains is usually 
required. If no effect is visible in ten or twelve hours the dose may be 
further increased, as the patient is in much greater danger from the 
disease than he can possibly be from the drug. Chloral may be given 
by the mouth or by the rectum, but must always be well diluted. The 
single case of recovery which we have seen was one treated by the 
bromid of potassium. This infant took eight grains every two hours 
for three days, afterward smaller doses. The child must at all times be 
kept as quiet as possible, without unnecessary handling or bathing. If 
nursing or feeding by the mouth is impossible, because the jaws cannot 
be separated, the child may be fed by a tube passed through the nose. 
This is greatly to be preferred to rectal alimentation. Drugs may be 
administered in the same way. 

The Antitoxin Treatment. — This is of especial value in prophylaxis. 
To be efficient as a curative measure it must be used early, for after the 
disease has developed it is very doubtful whether much can be accom- 
plished by its use ; but as it is harmless, it should be employed and given 
both intraspmally and intravenously. 



EPIDEMIC HEMOGLOBINURIA (Winckel's Disease) 

The essential features of this disease are hemoglobinuria with icterus 
and cyanosis, this combination giving the skin a deeply bronzed hue 



FATTY DEGENERATION OF THE NEWLY BORN 93 

(maladie bronzee). It is a rare disease, but has generally occurred epi- 
demically in institutions. It is usually fatal. It is, without doubt, in- 
fectious, but its cause has not been discovered. Although generally 
called by the name of Winckel, who in 1$79 made a report upon an 
epidemic of twenty-three cases, the disease was quite well described by 
Charrin in 1873, with a report of fourteen cases, and observed by Bige- 
low, in Boston, in 1875. All the cases included in Whickers report 
occurred in one institution, affecting one-fourth of the children born 
during the period. 

There is cyanosis, with a more or less intense icterus of the skin and 
internal organs. The umbilical vessels are usually normal. The kid- 
neys are swollen, show small hemorrhages into their substance, and 
under the microscope the straight tubes are seen to be filled with crys- 
tals of hemoglobin, but contain no blood-cells. The bladder frequently 
contains brownish, smoky urine. The spleen is swollen and filled with 
blood pigment, which is diffused throughout the cells of the pulp, and 
free in the blood-vessels. Punctate hemorrhages are seen in most of 
the other viscera. 

The symptoms usually begin from the fourth to the eighth day after 
birth, and are fulminating in character, seldom lasting more than two 
days. There are rapid pulse and respiration, general restlessness, pros- 
tration, cyanosis, and general icterus, which may be intense. The tem- 
perature is normal or slightly elevated. There is rapid asthenia, often 
terminating in coma or convulsions. The urine is passed frequently, in 
small quantities. It is of a smoky color, and contains hemoglobin 
in considerable quantity, renal epithelium, and sometimes granular casts 
and blood-cells, but does not contain bile pigment. Albumin is some- 
times present, but not in large quantity. 

Treatment is of little avail, since all severe cases are fatal. 



FATTY DEGENERATION OF THE NEWLY BORN (Buhl's Disease) 

A disease has been described by the author whose name it bears, the 
essential nature and causation of which are unknown. It occurs as 
isolated cases, and is characterized by inflammatory changes leading to 
fatty degeneration in the viscera, especially the heart, liver, and kidneys ; 
it seldom lasts more than two weeks, and is almost invariably fatal. 
Many of the lesions are similar to the ordinary post mortem changes, 
and when found they should not be interpreted as pathological unless 
the autopsy is made within twelve hours after death. 

The clinical features of this disease, as described, resemble those of 
pyogenic infection; and since the observations were made before modern 
5 



94 DISEASES OF THE NEWLY BORN 

methods of bacteriological study, it is highly probable that Buhl's disease 
is merely a form of pyogenic infection in the newly born. 



PEMPHIGUS NEONATORUM— BULLOUS IMPETIGO 

Pemphigus is a term which designates a lesion rather than a disease. 
By it is meant an eruption of bullae occurring usually upon a red base, 
the contents being in most cases clear serum. A condition somewhat 
resembling pemphigus sometimes follows the use in the newly born of 
too hot baths. Again, bullae are seen as one of the lesions of congenital 
syphilis; they are then usually present at birth or appear soon after. 
They are most frequently seen upon the palms and soles. Infants so 
affected are generally in wretched condition, and soon die. 

The only condition to which the term pemphigus neonatorum should 
be applied is quite different from both the preceding, and it has nothing 
in common with the pemphigus of later life. A better name is bullous 
impetigo, for its identity with impetigo contagiosa seen in older patients 
is now generally admitted. The disease is infectious, somewhat con- 
tagious, and occasionally occurs in small epidemics in institutions. Its 
spread in communities has been traced to midwives. The only important 
difference between this disease and the common impetigo contagiosa 
seen in older children, is its severity and its association with visceral 
infections. Most patients with bullous impetigo are delicate, neglected, 
and living in dirty surroundings; but not all are. We have seen it in 
robust infants who had received fairly good care. 

The greater number of cases studied thus far have shown the pres- 
ence in the blebs of the staphylococcus pyogenes aureus; less frequently 
the streptococcus has been the cause. The staphylococcus aureus was 
found in several typical cases occurring in our own hospital service. In 
one of these which came to autopsy, a general staphylococcus septicemia 
was present. 

The clinical picture presented by pemphigus neonatorum is so strik- 
ing that it can scarcely be mistaken. The symptoms begin in most 
cases between the fourth and tenth day of life. The bullae first appear- 
ing are scattered and often not larger than one-fourth or one-half inch 
in diameter. They may be seen upon any part of the body, but arc 
especially frequent about the face, hands, and other exposed parts. They 
rupture or dry and form crusts without suppuration. The small bullae 
may gradually increase in size or several may coalesce until they cover 
an area two or three inches in diameter. As the disease progresses, new 
bullae may appear over almost any part of the body. The skin is at first 
slightly reddened, then an exudation of serum occurs beneath the 1 epi- 



PEMPHIGUS NEONATORUM 95 

dermis which loosens and slides upon the true skin. After rupture of 
the large bullae, the epidermis at the margin forms a thin filmy border 
or hangs in shreds easily detached. The base of the large vesicles is 
a moist bright-red surface. When many have formed the appearance 
closely resembles that seen after an extensive burn. 

The course of the local symptoms is at first slow ; then the bullae may 
spread with great rapidity and death occur in from twenty-four to forty- 
eight hours. In less severe cases the course is more prolonged, the blebs 
are smaller, and recovery may take place. 

The constitutional symptoms are at first wanting, but increase with 
the number and extent of the bullae. There may be a slight rise of 
temperature or it may be subnormal. There is progressive weakness and 




Fig. 8. — Pemphigus Neonatorum. Symptoms began on 13th day; death on 16th day of 
asthenia; temperature subnormal. The dark areas in the picture are entirely denuded 
of epidermis; they were formed by the coalescence of large bullae. 

great depression, much like that following a burn, and death occurs 
from exhaustion or from some visceral inflammation such as pneumonia 
or meningitis. 

A disease very closely allied to pemphigus neonatorum in its etiology 
and clinical symptoms is dermatitis exfoliativa (Eitter). This also 
is due to infection with staphylococci which are found not only in the 
skin but often in the blood and viscera. The cutaneous lesions when 
typical may readily be differentiated from pemphigus, but there are 
many instances in which the lesions of both conditions may be present 
at the same time. A further similarity is found in the fact that in 
institutional epidemics both forms of disease may occur side by side. 
pemphigus in some infants, dermatitis exfoliativa in others. There is 
at first a redness and slight swelling of the skin which usually occurs 
first around the mouth, spreading upon the face, and then appears 
upon the extremities and trunk. The skin seems as if macerated and 
eventually exfoliates in large masses, leaving exposed the red corium 
from which some serous exudation takes place but there is no accumula- 



96 DISEASES OF THE NEWLY BORN 

tion of fluid beneath the epidermis before the separation of the overlying 
skin. The area denuded may be very great, sometimes fully half the 
body being thus exposed. Death often results in two or three days. In 
other eases, it is delayed for a week or ten days. In some, recovery 
occurs. The general symptoms are similar to those seen in pemphigus. 

It is important to distinguish pemphigus neonatorum from congenital 
syphilis. In syphilitic cases, the liver and spleen are usually markedly 
enlarged, and other characteristic changes may be present in the nails, 
mucous membranes, or elsewhere. 

Treatment is of little avail in the most severe cases, when the bullae 
cover a considerable part of the surface of the body. The bullae should 
be opened and drained, and the surfaces dressed with gauze covered with 
a two-per-cent ointment of white precipitate. There is little danger of 
mercurial poisoning. When dressings are changed the skin should be 
sponged with a bichlorid solution, 1-5,000 strength, or a one-per-cent 
solution of ichthyol or permanganate of potash. On account of the con- 
tagious nature of the disease cases occurring in institutions should be 
isolated. 



CHAPTEE Y 
HEMORRHAGES 

Hemoerhages are quite frequent during the first days of life, and 
are important not only from the fact that they are gften the cause of 
death, but, when the brain is the seat, from their remote effects. There 
are several conditions in the newly born which predispose to bleeding — 
the extreme delicacy of the blood-vessels, and the great changes taking 
place in the blood itself and in the circulation in the transition from 
intra-uterine to extra-uterine life. Hemorrhages may complicate many 
of the diseases of the early days of life, such as syphilis or sepsis, or they 
may exist alone. 

The cases may be divided into two groups: (1) Traumatic or Acci- 
dental Hemorrhages, which depend upon causes connected with delivery ; 
(2) Spontaneous Hemorrhages, or The Hemorrhagic Disease of the 
Newly Born. 

TRAUMATIC "OR ACCIDENTAL HEMORRHAGES 

These are mainly due to pressure in natural labor, or to means em- 
ployed in artificial delivery, but some of them may possibly result from 
injuries received before birth. They' are more frequent in large children, 



HEMATOMA OF THE STERNOMASTOID 97 

in difficult labors, and where from any cause the body of the child has 
been subjected to undue pressure. 

Hematoma of the Sternomastoid. — Hematoma of the sternomastoid 
muscle leads to the formation of a tumor in the belly of the muscle. 
It is a rather rare condition, usually noticed in the second or third week 
of life, and it disappears spontaneously, rarely causing any permanent 
deformity. The tumor varies from three quarters of an inch to one 
inch and a half in length, being about the size and shape of a pigeon's 
egg. It is movable, almost cartilaginous to the touch, and sometimes 
slightly tender. The situation of the tumor is usually about the center 
of the muscle. There is no discoloration of the skin. 

In about two-thirds of the cases it occurs after breech presentations. 
It is much more frequent upon the right than upon the left side. In 
twenty-seven cases collected by Henoch the right side was involved in 
twenty-one and the left in only six cases. The explanation of this differ- 
ence is to be found in the obstetrical position. Rarely, both sides may 
be involved. The head is usually slightly inclined toward the shoulder 
of the affected side and rotated toward the opposite side. The swelling 
slowly diminishes in size, and in most cases by the end of the 'third 
month has nearly or quite disappeared. Occasionally a slight torticollis 
remains for a longer time, but in the majority of cases the recovery is 
perfect. Hematoma of the sternomastoid is due to the twisting of the 
head during parturition. It is not an evidence of the employment of 
any improper force in delivery. The twisting of the head produces 
laceration of some of the blood-vessels of the muscle, and in some cases 
there is doubtless rupture of some of the fibers of the muscle itself. 
Following this there occurs a certain amount of inflammation of the 
muscle and its sheath. The tumor is due partly to blood-extravasation 
and partly to inflammatory products. In one or two recent cases in 
which the sheath of the muscle has been opened it has been found filled 
with blood. 

The condition requires no treatment. Operative interference is posi- 
tively contra-indicated. 

Cephalhematoma. — This is a tumor containing blood, situated upon 
the head, usually over one parietal bone, and tending to spontaneous 
disappearance by absorption. The source of the blood is the rupture of 
the small vessels of the pericranium. 

Etiology. — Cephalhematoma is sometimes due to a distinct trauma- 
tism like the application of forceps or to some other injury during 
labor. In the majority of cases, however, there is no evidence of such 
injury. Besides the conditions predisposing to all hemorrhages, there 
is the increased pressure in the blood-vessels of the head during delivery, 
especially when labor is prolonged or difficult; there may be changes in 



98 



DISEASES OF THE NEWLY BORN 



the bone, such as an imperfect development of the external table; and, 
finally, there may be changes in the blood itself. Cephalhematoma is 
a comparatively rare condition; it was present according to the statis- 
tics of the Sloane Hospital for Women, in 20 of 1,300 consecutive births, 
or 1.6 per cent. The condition is more common after first or difficult 
labors, and in vertex presentations; occurring twice as often in males 
as in females, probably from the greater size of the head. 

Lesions. — In the 20 Sloane cases, the situation was over the right 
parietal bone in 12 ; over the left in 2 ; over both parietals in 4; over the 
occipital in 2. The location of the tumor seems to have a very close 
relation to the position of the head in the pelvis. In 8 of the right-sided 

cases the head was in the left 
occipito-anterior position. Of 
the cases with occipital tumors, 
both were breech presentations. 
Of the 16 cases with a single 
tumor the labor was natural in 
10, tedious in 4, and in 2 for- 
ceps were used. Of the 4 double 
cases, 2 were forceps deliveries. 
In rare cases triple tumors 
are met with, one over each 
parietal and one over the occip- 
ital bone (Fig. 9). The attach- 
ment of the periosteum along 
the sutures usually limits the 
tumor to the surface of one bone. 
It never extends across the su- 
tures or over the fontanel. In 
cases where there is a more definite injury, such as that from forceps, the 
tumor may be present over any one of the cranial bones, but more fre- 
quently over the parietal. The seat of the hemorrhage is between the 
periosteum and the cranium. The scalp shows punctate hemorrhages and 
sometimes infiltration with blood. In recent cases the blood is fluid ; later 
it is coagulated. The amount of extra vasated blood is usually from half 
an ounce to an ounce. The cases following natural delivery are generally 
uncomplicated. The traumatic cases may be complicated by extrava- 
sations between the bone and the dura (internal cephalhematoma), or 
by meningeal or cerebral hemorrhages. If there is a wound, infection 
may be followed by purulent meningitis and even by cerebral abscess. 

Symptoms. — The tumor is usually noticed from the first to the 
fourth day after birth, appearing as a slight prominence in one of 
the positions mentioned. (Jradnally increasing in size, it attains its 




Fig. 9.- 



-Triple Cephalhematoma. 
seven days old. 



Infant 



CEPHALHEMATOMA 99 

maximum at the end of a few days, and then slowly diminishes. In 
size and shape the usual tumor may be compared to the bowl of a 
tablespoon. In marked cases it may be one-third the size of the child's 
head. To the touch it is soft, elastic, fluctuating, and irreducible. 
It does not increase with the cry or cough. There is no extra heat 
and no signs of inflammation. Usually the tumor does not pulsate, 
although in rare instances pulsating cephalhematomata have been seen. 
Very soon the tumor is surrounded by a marginal ridge. At first 
this is apparently from coagulation of blood, but later it may be bony. 
The prominent ridge with the soft center gives a sensation some- 
what like that of a depressed fracture. Sometimes on pressure there is 
obtained a sort of parchment-crackling. This is generally found as the 
swelling is subsiding, and is sometimes clearly due to the formation 
of minute bony plates upon the inner surface of the periosteum. It 
may be found when there is nothing but thin coagula to explain it. In 
certain cases following severe traumatism, cephalhematoma may be 
complicated with wounds of the scalp, fracture of the skull, and even 
lacerations of the dura mater or the brain. In such cases the tumor 
may become inflamed, but in the spontaneous cases this is extremely rare. 
The usual signs of abscess develop, which may open externally or bur- 
row. Fortunately this termination is seldom seen. 

As a rule, without any interference the uncomplicated cases go on 
to recovery. The complete disappearance of the tumor may be expected 
in from six weeks to three months, depending on its size; but a hard, 
uneven elevation may remain at its site for a longer time. The cases 
due to severe traumatism are more serious, the gravity depending not 
upon the cephalhematoma but upon the complicating lesions. 

Diagnosis. — Cephalhematoma may be confounded with encephalocele. 
This, however, occurs along the line of the sutures or at the fontanels, is 
partially reducible, pressure causes cerebral symptoms, and frequently 
the tumor increases with respiratory movements. Caput succedaneum 
often appears in the same place as a cephalhematoma and at the same 
time, but this is an edematous, not a fluctuating tumor, and begins to 
disappear by the second or third day. From a depressed fracture of 
the skull, it is differentiated by the fact that in cephalhematoma then; 
is a tumor and not a depression; the prominent margin which is raised 
above the contour of the skull is not osseous and the skull can be felt 
at the bottom of the center of the tumor. 

Treatment. — The treatment in the uncomplicated cases is simply 
protective, all such cases tending to spontaneous recovery. No local or 
general treatment to promote absorption is required. The child should 
be so placed and so handled that no injury may be done to the affected 
part. Compresses are unnecessary. If complications exist, such as in- 



100 DISEASES OF THE NEWLY BORN 

jury to the bones, dura, or brain, they are to be treated in accordance 
with general surgical principles. Operative interference is called for 
only when suppuration has occurred, or when there are brain symptoms 
which point to the existence of internal as well as external cephalhema- 
toma. 

Visceral Hemorrhages. — While these are most frequent in large chil- 
dren and following difficult labors, they may occur in small children 
and where the labor has been easy and normal — their occurrence here 
being due to the feeble resistance of the blood-vessels. From one hun- 
dred and thirty autopsies upon still-born children or those dying soon 
after birth, Spencer concludes that intracranial hemorrhages are more 
frequent in head-forceps than in breech cases, and more frequent in 
breech than in natural vertex deliveries. Other visceral hemorrhages 
are much more frequent in breech cases. 

Not all visceral hemorrhages are to be classed as traumatic. They 
are often seen with the spontaneous hemorrhages from the skin or 
mucous membranes. When, however, they are single, they seem to be 
of traumatic rather than of pathological origin. 

The most important of the visceral hemorrhages are intracranial. 
These are discussed in the chapter devoted to Birth Paralyses. Earely 
there may be large hemorrhages into the lung. Here the blood fills the 
air vesicles and the small bronchi, and coagula may be found even in the 
larger bronchi. A large part of a lobe or an entire lobe may be involved. 
On section the condition resembles atelectasis, and it may give the physi- 
cal signs of consolidation. 

The abdominal viscera suffer more than those of the thorax because 
less protected against pressure. Small hemorrhages are not uncommon 
upon the surface of any of the viscera covered by peritoneum. Intra- 
peritoneal hemorrhages are rare, but may be very extensive, amounting 
to six or eight ounces. Sometimes no ruptured vessel can be found. The 
hemorrhage may be primarily in the peritoneal cavity, or it may result 
from rupture of one of the viscera, especially the suprarenal capsule. It 
may be large enough to produce death from loss of blood. 

Small surface hemorrhages of the liver are not infrequent. Occa- 
sionally one of considerable size occurs separating the peritoneal cover- 
ing and forming a tumor generally upon the superior surface. Such 
laceration may be produced during labor, and a slow accumulation of 
blood may take place beneath the capsule, death resulting from rupture 
into the peritoneal cavity. Laceration of the capsule of the liver in a 
still-born infant has been reported. Of the large hemorrhages, those 
into the suprarenal capsules are perhaps the most frequent. The cap- 
sule may be distended to nearly the size of an orange, the kidney being 
surrounded by a mass of blood-clots. Blood may be extravasated into 



SPONTANEOUS HEMORRHAGES 101 

the retroperitoneal connective tissue and rupture may take, place into 
the peritoneal cavity. 

Except in the intracranial variety, visceral hemorrhages cause few 
symptoms, and in the great majority of cases the diagnosis is not made. 
Intrapulmonary hemorrhages have given rise to the signs. of consolida- 
tion of the lung and even to hemoptysis. The abdominal hemorrhages 
are the most obscure. There may be a general abdominal distention 
with the usual symptoms of loss of blood, or there may be a circum- 
scribed swelling. In many cases nothing is noticed until rupture of a 
subperitoneal hemorrhage takes place into the general peritoneal cavity, 
when there may be sudden collapse and death. 

The visceral hemorrhages are not amenable to treatment. The prog- 
nosis depends upon the size and position of the hemorrhage. In the cases 
of abdominal hemorrhage the diagnosis is extremely obscure and is rarely 
made during life. 



SPONTANEOUS HEMORRHAGES— THE HEMORRHAGIC DISEASE OF 

THE NEWLY BORN 

A disposition to bleeding is seen with many diseases of the first few 
days of life, especially those of an infectious character like syphilis and 
pyemia. With most of these, however, the hemorrhages are small and 
the condition may be compared to the hemorrhagic tendency seen in 
certain forms of infection of later life, such as measles, smallpox, and 
malignant endocarditis. There is, however, a class of cases in which the 
hemorrhages are not associated with any other known process, and in 
which the escape of blood from the small blood-vessels is the chief or 
essential symptom. In these cases the bleeding is much more extensive 
than in the others mentioned. These hemorrhages are characterized 
by the fact that they are spontaneous in origin, having no connection 
with delivery, they are multiple in location, they tend to cease spon- 
taneously after quite a limited time, but they are often greatly influenced 
l>\ treatment, They are most often from the mucous membranes of 
the stomach and intestines, or from the umbilicus or beneath the skin, 
but they may be from almost any mucous surface or into any organ of 
the body. 

Etiology. — These hemorrhages are not common, and are met with 
more often in institutions than in private practice. Tn 5,225 births in 
the Boston Lying-in Asylum, Townsend reports 32 cases of hemor- 
rhage, or 0.0 per cent. In the Lying-in Asylum of Prague, Bitter ob- 
served 100 eases in 13,000 births, or 1.4 per cent. In the Foundling 
Asylum of Prague, Epstein reports hemorrhages in 8 per cent of 1 10 
infants. 



102 DISEASES OF THE NEWLY BORN 

The condition is not a manifestation of hemophilia. Only 12 of 
576 bleeders whose histories were collected by Grandidier had a his- 
tory of hemorrhage at the time of the falling oif of the cord, and symp- 
toms very rarely appeared before the end of the first year. Hemorrhages 
in the newly born are only slightly more frequent in males, while in 
hemophilia they predominate 13 to 1. The hemorrhagic disease of the 
newly born is self-limited, and runs a definite course to recovery or 
death. The tendency to bleed does not extend beyond a few weeks, and 
often lasts but a few days. Circumcision has been done within a few 
days after the cessation of the hemorrhages without any unusual bleed- 
ing. In a case under our observation with the most extensive subcutane- 
ous hemorrhages we have ever seen, all tendency to bleed had ceased 
before the separation of the cord, although there had previously been 
bleeding at the navel. The bleeding occurs with about equal frequency 
in feeble and in well-nourished infants. Syphilis is associated in but a 
small proportion of the cases. On the other hand of 132 cases of 
congenital syphilis observed by Mracek, only 14 per cent suffered from 
hemorrhages. 

An association with sepsis has sometimes been noted. Of the 61 
cases observed by Epstein not less than 29, and of the 190 cases of Eitter, 
24 were associated with sepsis. During one year of our service at the 
Nursery and Child's Hospital there were 8 marked cases of hemorrhage 
in about 225 deliveries. While more cases of sepsis occurred among 
the children during that year than usual, it was striking that not one of 
these hemorrhagic cases gave any evidence of sepsis, and that none of the 
septic cases had bleeding. Yet the circumstances in which these hemor- 
rhages sometimes occur point strongly to an infectious origin. The 
results, often remarkable, following the injection of human blood serum 
indicate that the essential cause, in the largest number of cases, is a lack 
of some substance in the blood essential to coagulation. Sufficient studies 
have not yet been made to establish the precise nature of these blood 
changes. The results of treatment would seem to show that the cause of 
these hemorrhages is not always the same. 

While the hemorrhages are not traumatic, bleeding is exceedingly 
prone to occur in the skin over pressure points such as the back, the 
elbows, the occiput, and the sacrum.. It is also common from the mucous 
membranes which are the seat of pathological processes, especially from 
the eyes, the nose, and the genitals. 

Lesions. — In very many of the cases the autopsy shows nothing except 
the hemorrhages in the various situations and the blanching of the 
organs due to the loss of blood. The hemorrhages of the brain are usu- 
ally meningeal and diffuse. They are considered more at length in the 
chapter upon Birth Paralyses. The pulmonary hemorrhages are usu- 



SPONTANEOUS HEMORRHAGES 103 

ally small and unimportant, and large hemorrhages into the pleura or 
pericardium are very rare. The stomach and intestines may contain 
considerable blood variously disorganized in the different parts of the 
canal, and there may be ecchymoses of the mucous membrane. In addi- 
tion, ulcers may be found in the stomach and duodenum. In twenty- 
four autopsies upon cases with hemorrhage from the stomach and intes- 
tines collected by Dusser, ulcers were found in the stomach in nine 
cases, and in the intestines in four. These ulcers are multiple, small, 
and usually superficial, but may extend to the muscular coat and may 
even perforate. The intestinal ulcers are found only in the duodenum 
and resemble those of the stomach. The cause of these ulcers is some- 
what obscure; some of them are undoubtedly dependent upon inflam- 
matory changes, probably of infectious origin; others have been com- 
pared to the peptic ulcers of later life, and are attributed to thrombi in 
the blood-vessels of the mucous membrane. These ulcers are found 
m but a small proportion of the cases in which bleeding occurs from 
the alimentary tract, and they may be wanting even when it has been 
very profuse. Small extravasations may be seen upon the surface or 
in the substance of any of the abdominal organs. The changes found 
in the blood have not been uniform. 

Symptoms. — The onset is most frequently in the first week of life; 
very rarely after the twelfth day. The hemorrhages are usually mul- 
tiple. Their location in Bitter's 190 cases was as follows : Umbilicus, 
138 (umbilicus alone, 97); intestines, 39; mouth, 28; stomach, 20; 
conjunctivae, 20; ears, 9. In Townsend's 50 cases: Intestines, 20; 
stomach, 14; mouth, 11; nose, 12; umbilicus, 18 (umbilicus alone, 3) ; 
subcutaneous ecchymoses, 21; abrasion of skin, 1; meninges, 4; cephal- 
hematoma, 3 ; abdomen, 2 ; pleura, lungs, and thymus, 1 each. 

In many cases nothing is noticed until the hemorrhage begins. The 
first bleeding noticed may be from the stomach, intestines, or any of the 
mucous surfaces, beneath the skin, or from the umbilicus. The amount 
of blood lost in most cases is not great, but there is a continuous oozing. 
The total hemorrhage may be only a few drams or it may reach several 
ounces. The general condition is one of considerable prostration, often 
from the outset. In all cases there is rapid loss of weight. The tem- 
perature may be high, low, or subnormal. A marked elevation of 
temperature may depend not upon the hemorrhage but upon associated 
conditions. In a large number of the cases there is diarrhea. 

The duration of the disease in cases which recover is usually but one 
or two days. In fatal cases it is rarely more than three days, and often 
less than one. Death may result from the gradual failure of all the vital 
forces or from rapid loss of blood. 

Umbilical Hemorrhage. — A slight oozing from the umbilicus not in- 



104 DISEASES OF THE NEWLY BORN 

frequently occurs when the ligature has been improperly applied. This 
is generally controlled by simple measures. Spontaneous hemorrhage 
is quite different. It occurs rather later than bleeding from the mucous 
membranes, usually occurring between the fourth and the seventh day. 
There may be bleeding into the cord as well as from its free extremity. 
A slight stain upon the dressing is usually the first note of warning, 
but in exceptional circumstances a gush of blood is the first symptom. 
The hemorrhage may be temporarily arrested by various means, but it 
shows a strong tendency to recur in spite of everything which is done. 
The usual duration is two or three days. It has been known, however, 
to persist for twelve or fourteen days, and it may be fatal in less than 
twenty-four hours from the time it is noticed. 

Hemorrhage from the Stomach and Intestines. — Bleeding occurs 
much less frequently from the stomach than from the intestines. The 
latter is called melena. Gastro-enteric hemorrhages begin, in the great 
majority of cases, during the first three days of life. The blood vomited 
is usually in dark-brown masses, and not very abundant; more rarely 
it is bright reel. The quantity varies from one dram to half an ounce. 
Vomiting is liable to be excited by nursing. The blood discharged from 
the bowels is always dark colored, usually intimately mixed with the 
stool, very rarely in clots. If in doubt between blood and meconium, 
one should look for the corpuscles with the microscope. When this is 
not conclusive on account of the disorganization of the corpuscles, a 
chemical test for hemoglobin should be made. Concealed hemorrhage 
into the stomach may take place, which may even be sufficient to pro- 
duce death, no blood being vomited or passed by the bowels. In such 
cases the autopsy may reveal quite a large quantity of blood both in the 
stomach and intestines. 

Hemorrhage from the Mouth. — The quantity of blood is rarely large; 
but it is here that it is often first seen. Its source may be the mucous 
membrane of the mouth, pharynx, esophagus, stomach, or bronchi. It 
may be associated with ulceration of the hard palate, with thrush, or with 
fissures of the lips. 

Hemorrhages from the nose are infrequent, and are more often due to 
syphilis than to other causes. These are rarely profuse, but are fre- 
quently repeated. 

Subcutaneous Hemorrhages. — These often appear in places exposed 
to pressure, such as the sacrum, heels, occiput, or back, but may occur 
anywhere. In some cases these hemorrhages are very extensive, as in 
one recently under observation, where nearly one-third of the thorax was 
covered. When they occur alone or form the principal lesion, the prog- 
nosis is favorable. 

Hematuria. — The urine is not only stained with blood, but some- 



SPONTANEOUS HEMORRHAGES 105 

times contains clots. This hemorrhage may have its origin in the blad- 
der, urethra, or kidney. Blood coming from the kidney is sometimes 
due to the irritation of uric-acid infarctions, and may have nothing to 
do with the general hemorrhagic disease. 

Hemorrhage from the Conjunctiva.— -The blood usually comes in 
drops from between the eyelids, chiefly from the tarsal surface. It is 
generally preceded by conjunctivitis. 

Hemorrhage from the Female Genitals. — This not infrequently oc- 
curs without hemorrhages elsewhere, and under such circumstances is 
rarely serious. Cullingsworth collected thirty-two cases in children 
under six weeks of K age — no case having resulted fatally. These are not 
to be regarded as cases of precocious menstruation. 

Diagnosis. — This is generally easy, as the hemorrhages are usually 
multiple and some of them external. A slight hemorrhage from the 
intestine may be easily overlooked. Large hemorrhages into the in- 
ternal organs also are obscure and not often recognized. Spurious 
hemorrhages from the stomach may occur, blood being vomited which 
has been swallowed during birth or nursing. The source of bleeding 
may also be the mouth, nose, or pharynx, and sometimes blood is swal- 
lowed in large quantities and afterward vomited. These cavities should 
therefore always be examined, since local treatment may be efficacious. 
Syphilis should be suspected when the bleeding is chiefly nasal. 

Prognosis. — Before the introduction of treatment with human blood 
serum the hemorrhagic disease in the newly born had a very bad prog- 
nosis. Of 709 cases collected by Townsend, the mortality was 79 per 
cent. No case should be looked upon as hopeless, for perfect recovery 
has repeatedly taken place when it seemed impossible. 

Treatment. — Local measures may be employed in all external hemor- 
rhages with some prospect of benefit. The bleeding points may be 
touched with persulphate of iron or with chromic acid fused upon a 
probe, or fresh human blood or human serum may be applied locally. 
These measures may be employed alone or in combination with pressure. 

Although recoveries have been reported following the use of a great 
variety of remedies, it is by no means established that the result was 
due to the drugs employed. Many of the milder cases recover without 
any special treatment. On the whole, the medicinal treatment is very 
unsatisfactory. Epinephrin is of doubtful benefit. Gelatin has had many 
advocates. It is used by subcutaneous injection. A 5-to-10-per-cent 
solution which has been twice sterilized is employed, from 25 to 50 c. c. 
being administered two or three times daily. Calcium lactate in some 
instances appears to exert a positive effect. It may be given in frequently 
repeated doses up to 20 or 30 grains a day. 

The most efficient treatment is transfusion, first practiced by Carrel- 



106 DISEASES OF THE NEWLY BORN 

It should, if possible, be performed whenever the loss of blood has been 
great. From 90 to 150 c. c. may be given. This not only replaces blood 
lost but, in the vast majority of cases, stops further bleeding at once. Its 
action seems specific and the effects of transfusion are often truly mar- 
velous. That the subcutaneous or intramuscular injection of human blood 
serum would control these hemorrhages was first shown by J. E. Welch. 
Almost equally efficacious is the injection of human blood in the same 
manner. Usually 30 to 40 c. c. of blood or blood serum is injected at one 
time, and this should be repeated every few hours, if bleeding continues. 
For transfusion, only the blood of a parent should be used without pre- 
vious hemolytic tests ; for subcutaneous use, blood from any healthy person 
will answer as well. The subcutaneous injection of horse serum has a 
certain value in these cases and should be employed when it is impractical 
to obtain human blood serum. It is, however, distinctly inferior. In 
some instances thrombin, prepared according to the method of Howell, 
has caused a cessation of the hemorrhage. A small proportion of patients, 
however, are not improved by the measures mentioned, and in spite of 
them bleeding may continue. These suggest a different etiology of 
which we have as yet no clue. The general treatment should have refer- 
ence to maintaining the nutrition by careful feeding, judicious stimula- 
tion, and attention to the circulation, the body temperature, and the 
general condition of the child. 



CHAPTEK VI 
BIRTH PARALYSES 

Birth paralyses are chiefly due either to pressure upon the child by 
the parts of the mother or to artificial means employed in delivery. 
They may be cerebral, spinal, or peripheral. 

Cerebral paralyses are in almost every instance due to meningeal 
hemorrhage, and accompanied by a certain amount of injury to the 
brain substance. Very infrequently they depend upon cerebral hemor- 
rhage, laceration of the brain, or pressure from a depressed fracture. 

Spinal paralyses are extremely rare, and only a few examples are on 
record. They are due to laceration of, or hemorrhage into, the cord or 
its membranes. These lesions produce paraplegia, the exact distribution 
of which depends upon the point at which the cord is injured. 

Peripheral paralyses usually affect the face or the upper extremity. 
Paralysis of the face is due in most cases to the application of for- 
ceps. Paralysis of the upper extremity is most frequently of the "upper- 



CEREBRAL PARALYSIS 



107 



arm type/' and is known as the Duchenne-Erb paralysis. It usually fol- 
lows extraction in breech presentations. Peripheral paralysis of the lower 
extremity is almost unknown. 

CEREBRAL PARALYSIS 



ing the last 
pregnancy. 



Cerebral paralysis is often used synonymously with meningeal hemor- 
rhage. This lesion is not infrequent, and is of great importance not 
only from its immediate effects, but because upon it depend many of the 
cerebral paralyses seen in later life. According to Cruveilhier, at least 
one-third of the deaths of infants which occur during parturition are 
due to this cause. 

Etiology. — The same predisposing causes exist in the cases of menin- 
geal hemorrhages as in others occurring at this time. A small number 
of cases are associated 

with syphilis; others N 

with pyogenic infection. 
In a few cases there is a 
history of an injury — 
usually a fall or blow 
upon the abdomen — dur- 
months of 
Meningeal 
hemorrhage may occur as 
one of the lesions in the 
hemorrhagic disease of 
the newly born. The 
most important causes, 
however, are connected 
with parturition. These 
hemorrhages are essen- 
tially mechanical, and 
are favored by every- 
thing which increases or 
prolongs pressure upon 

I he head. The conditions with which they are associated are tedious labor, 
breech presentations with difficulty in extracting the head, instrumental 
deliveries, and premature births. The majority occur in first-born chil- 
dren. In many of the cases there is also a hemorrhage outside the skull. 

Lesions. — The hemorrhages may be large or small. Tf small, they 
are frequently multiple and are found scattered over the convexity. 
In such circumstances they are usually beneath the arachnoid. 
Edema of the brain is often associated with them. It is doubtful if 




Fig. 10, 
Born. 



-Meningeal Hemorrhage of the Newly 
(Extravasation above the Tentorium.) 



108 DISEASES OF THE NEWLY BORN 

very small hemorrhages that may cause little more than a discolora- 
tion of the meninges are sufficient to account for death. They are 
found so frequently when there have been no symptoms referable to the 
brain that it is a question if they are not quite a common sequel of 
labor. Larger hemorrhages may be at the base or at the convexity and 
either in the anterior or posterior part of the skull. When upon the 
convexity, the blood usually comes from the veins ascending from the 
middle cerebral region to the lateral aspects of the superior longi- 
tudinal sinus. These are lacerated by the over-lapping of the parietal 
bones. Convexity hemorrhages are rarely limited to one hemisphere, 
although the one side may be much more affected. It is usual for 
the blood to gravitate toward the base and become diffused. Nearly 
the entire surface of the brain may be covered. Hemorrhages are fre- 
quently found over the cerebellum and the occipital lobes of the cere- 
brum; these are usually due to rupture of the tentorium. While this 
may allow of some extravasation of blood above the tentorium, the 
entire extravasation is often beneath it. Eupture of the tentorium 
is usually due to marked lateral compression of the head, but may 
occur when the pressure is anteroposterior. It is apparent that hemor- 
rhages may result very rarely from marked venous congestion. In this 
way is explained the hemorrhage which is occasionally found in the 
lateral ventricles alone. This comes from rupture of the straight sinus 
or of the great vein of Galen. Hemorrhages between the dura and the 
skull may be said never to occur except when associated with fracture. 
If the child is still-born, or, if death has occurred on the first or second 
day, the blood is partly fluid and partly coagulated; later it is entirely 
coagulated and may have undergone partial absorption. The amount 
of extravasated blood varies between one dram and two ounces, the aver- 
age amount being about one-half ounce. The blood extends into the 
fissures between the convolutions and sometimes into the ventricles 
along the choroid plexus, although this is rare. In large hemorrhages 
the brain substance is softened and in places may be quite disintegrated ; 
but with small extravasations these changes are very slight and hard 
to demonstrate to the naked eye. In cases which survive for two or 
three weeks there is usually a certain amount of meningitis. The later 
changes — those of arrested development of the cortex and cerebral sclero- 
sis — will be considered in the chapter devoted to Cerebral Paralyses 
in the section on Diseases of the Nervous System. Hemorrhages into 
the membranes of the upper part of the cord are found in a large pro- 
portion of the fatal cases. Associated hemorrhages of the lungs and 
other organs are not uncommon. 

Symptoms. — If the hemorrhage is large, the child is usually still- 
born, although the fetal movements may have been, active up to the 



CEREBRAL PARALYSIS 109 

commencement of labor. When the hemorrhage is not so large as to be 
immediately fatal, the child may show no symptoms except dulness or 
stupor, with feeble or irregular respiration, death following within the 
first twenty-four hours. A large proportion of the infants are born 
asphyxiated, and frequently they are resuscitated only after consider- 
able effort. They nurse feebly or not at all. Convulsions are common 
in cases which last for four or five days, and more with hemorrhages 
at the convexity than with those at the base. Opisthotonus is often 
present, also general rigidity of the extremities, clenching of the hands, 
and increased knee-jerks. Barely there is complete relaxation of all 
the muscles. Sometimes there are automatic movements. The respira- 
tion is usually disturbed; in most cases it is slow and irregular. The 
pulse is feeble and usually slow. The pupils are more frequently con- 
tracted than dilated, and there may be oscillation of the eyeballs. There 
may be a slight exophthalmus. In large hemorrhages there is marke-d 
bulging of the fontanel, and often separation of the sutures. If the 
hemorrhage covers one hemisphere, there is complete hemiplegia of 
the opposite side. Small localized cortical hemorrhages may cause 
paralysis of the face, arm, or leg, according to the position of the lesion, 
or localized convulsions. In large hemorrhages at the base convulsions 
are rare, and death occurs early, usually in the first two clays. In 
extensive cortical hemorrhages convulsions and rigidity of the extremi- 
ties are frequent, and life may be prolonged indefinitely. There is 
usually no fever, but exceptionally the temperature may be high. 

The majority of the fatal cases die within the first four days. In 
those lasting a longer time the symptoms are tonic spasm of the trunk 
or of one or more of the extremities, with localized paralysis — mono- 
plegia, diplegia, or hemiplegia, according to the lesion — and localized 
or general convulsions often continuing for two or three weeks and 
gradually subsiding. In the mildest cases nothing abnormal may be 
noticed until the child is old enough to walk or talk. In those more 
severe there may be gradual and continuous improvement of the early 
symptoms, and the case may go on to apparent recovery, but usually 
there is some permanent damage to the brain. 

The main diagnostic symptoms in recent cases arc: bulging fontanel, 
slow pulse, stupor, rigidity, increased reflexes, convulsions, and paralysis, 
especially when localized, and opisthotonus. These vary with the extent 
and situation of the lesion. Lumbar puncture has very doubtful value. 

Prognosis. — A large hemorrhage at the base quickly causes death; 
if it is located at the convexity, although the child may survive, there is 
always serious damage to the brain. Even from small hemorrhages 
some permanent injury usually results, -though the extent of this may 
not be evident for years. 



110 DISEASES OF THE NEWLY BORN 

Treatment. — This is mainly prophylactic, the chief indication being 
to shorten tedious labors by the early use of the forceps. When the 
hemorrhage has been attributed to the forceps, the damage has prob- 
ably been the result of the long-continued pressure before they were used. 
Nothing can be done after delivery to limit the amount of the hemor- 
rhage, except to keep the child as quiet as possible. The removal of the 
clot by surgical operation has been successfully accomplished by Cushing 
and others. With more accurate diagnosis there seems to be no reason 
why a certain number may not be saved. For the best results opera- 
tion should be done as soon as possible. One great difficulty is that 
of early and accurate diagnosis. Paralysis whether localized or general 
is of greater value in diagnosis than are convulsions. The latter, how- 
ever, are especially important when localized or continuous and threat- 
ening life. The operative risk, while considerable, is not to be measured 
against the permanent mental deficiency usually resulting in most of 
these children when nothing is done. Cases with similar symptoms 
are sometimes seen in which there is no extravasation of blood found 
at operation, but only intense congestion with an excessive serous ex- 
udate. In them also relief may follow operation. The hopeless outlook 
for such cases when not relieved, justifies the taking of great risks. 



FACIAL PARALYSIS 

The usual cause of facial paralysis is the use of the forceps, but this 
does not explain all the cases. The etiology of those in which the for- 
ceps have not been used is still somewhat obscure. In peripheral facial 
palsy the nerve is pressed upon, either near its exit from the stylomas- 
toid foramen, or where it crosses the ramus of the jaw, at which point 
the parotid gland gives it but little protection in the newly born. If the 
lesion is in front of this point, any one of the terminal branches may 
be affected; most frequently it is the temporofacial branch. As only 
one blade of the forceps commonly touches the face in this region, the 
paralysis is, as a rule, unilateral. 

Eoulland has reported several cases not due to the forceps. In these 
the pressure is believed to have been produced by the promontory of the 
sacrum at the superior strait, or by the ischium at the inferior strait, as 
paralysis followed when the head was long arrested at one of these points. 
It was not seen with face or breech presentations. When facial paralysis 
is of central origin it depends generally upon a meningeal hemorrhage, 
and the arm and leg of the same side as the face are involved. It is, 
however, possible for a very small cortical hemorrhage to produce 
paralysis of the face only. 



BRACHIAL BIRTH PALSY 111 

In repose, the only symptom noticed may be that the eye remains 
open upon the affected side, owing to paralysis of the orbicularis palpe- 
brarum. When the muscles are called into action, as in crying, the 
whole side of the face is seen to be affected. The paralyzed side is 
smooth, full, and often appears to be somewhat swollen. The mouth 
is drawn to the side not affected. In this paralysis, the tongue, of course, 
is not implicated. It is therefore rare that nursing is seriously in- 
terfered with. 1 If the paralysis is of central origin, only the lower half 
of the face is involved, while in peripheral paralysis, as the trunk of 
the nerve is injured, the upper half of the face, including the orbicularis 
palpebrarum, is also affected. 

The paralysis is generally noticed on the first or second day of life, 
and does not increase in severity. Its course and termination depend 
upon the extent of the injury done to the nerve. Some idea of this may 
often be gained by the amount of injury to the soft parts, although this 
is not an infallible guide. In cases not due to the forceps, the paralysis 
is slight and disappears in a few days ; the great majority of the forceps 
cases follow the same favorable course, the paralysis gradually disap- 
pearing without treatment in about two weeks. In more serious cases 
it may last for months, or it may be permanent. The reaction of de- 
generation is present in these severe cases, and there may even be per- 
ceptible atrophy of the muscles. This symptom is fortunately extremely 
rare. 

Treatment. — Xothing should be done for the first ten days except to 
protect the eye and keep it clean. If improvement has begun by the end 
of this time, the probabilities are that the case will require no treatment. 
If no improvement has taken place by the end of the third or fourth 
week, electricity should be used regularly and systematically. If the 
muscles respond to it, the faradic current may be employed; if not, 
galvanism should be used. The electrical treatment should be continued 
for several months, or until recovery has taken place. 



BRACHIAL BIRTH PALSY 

This, sometimes called "obstetrical paralysis" or "Duehenne-Erb 
paralysis" is fortunately not a common condition. It is almost always 
unilateral, though occasionally both arms are involved. It may result 
from spontaneous delivery but is vastly more frequent following 
operative interference in difficult labor. In the majority of cases it 
is directly due to manipulation, though it may occur in the practice 

1 In this connection it is to be remembered that the principal part in nursing is 
done by the tongue, and not by the lips. 



112 



DISEASES OF THE NEWLY BORN 



of the most skillful. Pressure from the application of forceps, while 
a possibility, is an infrequent cause, though long regarded as the most 
important one. The injury may be produced by any manipulation that 
forcibly draws the head and neck away from the shoulder. This puts 
the brachial plexus upon the stretch. If the force is slight, only stretch- 
ing of the nerves is caused; if more extreme, laceration of the nerves 
is produced from above downward. The suprascapular nerve is by 
its position the one most exposed to injury and is the one that is first 
and most severely torn. The fifth cervical next is affected, then the sixth, 

the seventh and perhaps the 
eighth and the first dorsal. 
While the injury is almost 
always to the plexus alone 
it is probable that in some 
cases one or more of the 
roots in the cervical region 
may be torn from the cord. 
The amount of spontaneous 
improvement depends upon 
the extent of the lesion. 
When only overstretching 
has been produced, a com- 
plete recovery may take 
place. The same may be 
true when the laceration of 
the nerves has been slight 
and the ends remain in ap- 
position. When more ex- 
tensive injury has taken place complete recovery cannot be expected. 
Hemorrhage has occurred and there has been laceration of the fascia 
as well as the nerves. The result is usually the production of a cica- 
tricial mass that interrupts the continuity of the nerves and prevents 
their regeneration. The nerve impulses are thus blocked. 

The paralysis in severe cases is noticed soon after birth owing to 
the fact that the infant cannot use his arm. In less severe cases the 
paralysis may escape detection for several weeks. 

The most common form of peripheral paralysis is that known as 
the "upper-arm type/' The muscles paralyzed are the deltoid, biceps, 
brachialis anticus, supinator longus, and sometimes the supra- and infra- 
spinatus. All these muscles may be involved, or only part of them, and 
in varying degrees. The arm bangs lifeless by the side; it is rotated 
inward, the forearm pronated, the palm looking outward (Fig. 11). The 
forearm and hand are not affected, except in eases where the whole plexus 




Fig. 11. — Erb's Paralysis, Left Arm. 
Infant two months old. 



BRACHIAL BIRTH PALSY 113 

has been lacerated. In severe oases there may he anesthesia of the outer 
surface of the arm, in the region supplied by the circumflex and external 
cutaneous nerves. This is rarely marked, and in its slighter degrees it 
is very difficult to determine. It is characteristic of this paralysis that 
the triceps is not affected, so that power to extend the forearm remains, 
although it cannot be flexed. A nodular mass in the region of the plexus 
may be felt. This is the result of the hemorrhage and the inflammatory 
reaction. Atrophy of the paralyzed muscles occurs after a few weeks, but 
the muscles are so small and so covered with fat that it is rarely notice- 
able before the second year. It is most conspicuous in the deltoid. In 
all severe cases the reaction of degeneration is present. In some of the 
cases of long standing there occurs a shortening of the tendon of the 
subscapulars muscle, often associated with subluxation of the humerus. 
The paralysis may be complicated with fracture of the clavicle, the neck 
of the scapula, or the shaft of the humerus, or with epiphyseal separation 
of its head. Injury confined to one nerve is very uncommon. We have 
seen two cases in which there was temporary paralysis of only the muscles 
supplied by the musculo-spinal nerve. The explanation of such cases is 
obscure. 

The prognosis depends upon the severity of the injury. Some cases 
recover spontaneously in two or three months, improvement being ob- 
served within a few weeks, first in the biceps and last in the deltoid. 
Eecovery after many months may take place even in cases appar- 
ently severe. Gradual improvement may continue to the end of the sec- • 
ond year. The condition is, however, a very serious one. There is usually 
some permanent paralysis left and it may be so marked as to render the 
arm almost useless. Permanent paralysis is most frequently of the del- 
toid. 

The electrical reactions arc of some value in prognosis. If the mus- 
cles respond to faradism, rapid improvement can generally be prophesied. 
If the reaction of degeneration is present, improvement will be slow and 
the paralysis is likely to be permanent. 

The diagnosis is usually not difficult, since the great majority of cases 
are of the "upper-arm type" with classical symptoms. Peripheral palsy 
of the arm can scarcely be confounded with that of cerebral origin. If 
the lesion is central it is one of the rarest occurrences lor the arm alone 
to be involved; either the leg or face, or both, are generally likewise 
affected. If the case does not come under observation until the child is 
a year old, it may be difficult, or without a good history it may be impos- 
sible to distinguish peripheral paralysis from that due to poliomyelitis. 
The particular group of muscles involved in Erb's paralysis is the chief 
diagnostic point. 

In recent cases the disability resulting from the tenderness or pain of 



114 DISEASES OF THE NEWLY BORN 

syphilitic epiphysitis may simulate paralysis, but there is lacking the 
characteristic position of the arm, and a careful examination discloses 
the fact that the paralysis is only apparent. This may affect both sides. 
Fracture of the clavicle or epiphyseal separation of the head of the 
humerus may also be mistaken for paralysis. In cases of long standing, 
paralysis of the deltoid may resemble dislocation of the humerus. The 
reaction of degeneration differentiates paralysis from surgical injuries 
with similar deformities. 

Treatment. — As soon as the paralysis is discovered the injured arm 
should be put at rest by means of a sling, with the shoulder elevated in 
order to bring the ends of the nerves in apposition. At the end of two 
or three weeks gentle massage may be employed. In cases going on to 
permanent recovery improvement is rapid. At the end of two months 
it is generally possible to tell to what extent recovery will take place. If 
very little has been gained by that time, and if a surgeon expert in 
nerve surgery can be consulted, operation should be considered, for 
at this time less nerve degeneration will have taken place than at a 
later date and the regeneration of the nerves will require much less time. 
The operation consists in dissecting out and suturing the nerve trunks 
whose continuity has been broken by the injury. A. S. Taylor, New 
York, from an extended experience, has reported marked improvement 
in some otherwise hopeless cases by this operation. Though useful in 
mild cases, but little is to be expected from manipulation and electricity 
in severe cases without operation. 



CHAPTEK YII 
TUMORS OF THE UMBILICUS, MASTITIS, ETC. 

Granuloma. — This is nothing more than a mass of exuberant granu- 
lations at the umbilical stump. The mass is generally about the size of a 
pea — sometimes larger — bleeds readily, and has a thin, purulent dis- 
charge. It is promptly cured by the application of any simple astringent ; 
powdered alum is probably the best. In case this is not successful, the 
granulations may be touched with nitrate of silver or snipped off with 
scissors. 

Adenoma, Mucous Polypus, or Diverticulum Tumor — Umbilical Fis- 
tula. — The first three terms are used synonymously to describe an umbil- 
ical tumor covered with a mucous membrane which is similar in structure 
to that of the small intestine. It is usually associated with an umbilical 
fistula. This tumor is formed by a prolapse at the navel of the mucous 
membrane of Meckel's diverticulum. This diverticulum is the remains 



ADENOMA, MUCOUS POLYPUS, OR DIVERTICULUM TUMOR 115 

of the omphalomesenteric duct. When it is present in infants, it is found 
in various stages of development. Most frequently there is a blind pouch 
a few inches long given off from the lower part of the ileum. In other 
cases it may remain patent quite to the umbilicus, causing a fecal fistula 
(Fig. 12, A). As the intestine below it is generally normal, this fistula 
may persist for months or even years, giving rise to no symptoms except 
a slight fecal discharge from the umbilicus. In certain cases intestinal 
worms have been discharged through it. It may close spontaneously or 
be closed by operation. 

A prolapse of the mucous membrane lining the diverticulum produces 
an umbilical tumor with a fistula at its summit (Fig. 12, B). This is 
the most common form. A cross-section shows under the microscope the 




Fig. 12.- 



-Umbilical Fistula and Tumors Produced by Prolapse of Meckel's 
Diverticulum. (Barth.) 



structure of the intestinal mucous membrane both as an external covering 
and lining of the fistulous tract. The prolapse may involve not only the 
mucous membrane but the entire intestinal wall. There then exists a 
conical tumor with a fistula which has but one external opening, but at a 
short distance from the surface it bifurcates, one branch leading upward 
and one downward (Fig. 12, C). A continuation of the prolapse gives 
a broad pedunculated tumor (Fig. 12, D), which may reach the size of 
an orange. Its covering is the same as in the other forms. It may 
contain several coils of intestine. In this form there are usually two 
fistulous openings (a, b) which communicate with the intestine. 

In all of these cases the tumor is smooth, irreducible, of a rosy pink 
color, and from its surface there oozes a mucous discharge. Microscopical 
examination shows the external covering to be the same in structure as 
the intestinal mucous membrane. These tumors are generally small, 
varying in size from a pea to a small cherry, but they may be very much 
larger. A fecal fistula usually, but not invariably, coexists. In the con- 
dition represented in Fig. 12, B, it is easy to see how an obliteration of 
the fistula may occur. The small tumors are readily cured by tin; liga- 



110 DISEASES OF THE NEWLY BORN 

ture. The larger ones are usually associated with other serious mal- 
formations of the intestines, which make the outlook had in almost every 
instance. 

UMBILICAL HERNIA 

Hernia into the umbilical cord is a rare congenital condition of a 
serious nature. It is due to some fetal defect, and varies in size from 
a small protrusion to complete eventration in which nearly all the abdom- 
inal organs are outside the bgcly. Many cases in which only intestinal 
coils are contained in the sac, though the tumor is quite large, are amen- 
able to surgical treatment, which should be instituted at once. In the 
very large ones the prognosis is bad. 

The common umbilical hernia is quite a different condition, and 
while a source of much annoyance it is rarely serious. It is much more 
common in females than in males, and occurs especially in those who are 
poorly nourished and rachitic. The tumor is usually from one-fourth 
to one-half an inch in diameter ; it may, however, be very large, and may 
even become strangulated, when a surgical operation may become neces- 
sary. The ordinary cases, however, require only mechanical treatment. 
The most important thing is prevention. For this purpose it is neces- 
sary, after the cord has separated, to place a firm pad over the navel and 
to use a snug abdominal band for the first two or three months. After 
this period it is uncommon for hernia to develop. In cases coming under 
observation after the third or fourth month, the pad and abdominal 
bandage are inadequate, and other means must be employed to retain 
the hernia. The best of these consists in the use of two adhesive strips 
applied obliquely over the abdomen, crossing at the umbilicus, the skin 
along the median line being folded inward so as to overlap the tumor, 
this forming the retention pad. A simple method of retention is to place 
over the tumor a coin or button covered with kid and hold it in position 
by a strip of adhesive plaster ten or twelve inches long. One should be 
cautious about using the small conical pads frequently employed, as these 
tend to dilate the opening rather than to close it. If the skin is made 
absolutely clean and zinc-oxid plaster used, excoriations are rare. The 
dressing should be changed every week or ten days and worn for several 
months. After the first year all mechanical treatment is unsatisfactory. 
For the very small tumors it is really unnecessary to use any form of 
apparatus, since these cases ordinarily show little or no tendency to 
increase in size, and the retention apparatus causes more annoyance than 
the hernia. These small herniae sometimes disappear spontaneously dur- 
ing childhood, and rarely need be considered in children over seven years 
of age. Operation is seldom necessary. 



MASTITIS 117 



MASTITIS 



According to Guillot, a certain amount of secretion in the breasts of 
the newly born is physiological. It is certainly very common. It is most 
abundant between the eighth and fifteenth days, bnt may continue in 
small quantities as late as the third month. It is seen with equal fre- 
quency in both sexes. The quantity of the secretion amounts in most 
cases only to a few drops; in some, however, as much as a dram has 
been obtained. Chemical analysis has shown this secretion to be essen- 
tially the same as the adult milk — containing fat, sugar, protein, and 
salts. In gross appearance it resembles colostrum. The researches of 
Sinety have shown that the mammary gland of the newly born contains 
cul-de-sacs lined with secreting cells, resembling those of the adult. 
During the period of secretion the gland is slightly reddened, its vessels 
turgid, and all the signs of functional activity are present. This condi- 
tion in itself is of no practical importance, and in most cases, if left 
alone, the secretion ceases spontaneously after a week or ten days. It 
sometimes happens, however, that the presence of this secretion tempts 
the nurse or attendant to rub or squeeze the breast. Such manipulation 
occasionally leads to serious results by exciting a mastitis which may 
terminate in abscess. Mastitis is not a very rare condition, and although 
the inflammation is not usually severe, it may be serious and even fatal. 
The predisposing cause is the congestion which accompanies functional 
activity, usually in the second week. The exciting cause is most often 
some form of traumatism — undue pressure, the squeezing of the breasts, 
or rough handling by the nurse. Through abrasions or fissures thus pro- 
duced, microorganisms find a ready entrance with the same result as in 
the adult. It seems possible that the germs may enter through the lac- 
tiferous ducts without any abrasion of the skin. Want of cleanliness is 
always a favorable condition for such infection. 

The symptoms of mastitis usually begin during the second week of 
life. There is redness, swelling, and the usual signs of inflammation, 
which may terminate in resolution or in suppuration. The process may 
be limited to the mammary region, or a diffuse phlegmonous inflamma- 
tion may be set up, and the case terminate fatally. In the female it is 
possible for the cicatrization which follows such an inflammation to inter- 
fere with the subsequent development of the gland. The general symp- 
toms are restlessness, loss of sleep, disinclination to nurse, and loss of 
weight. In cases of diffuse phlegmonous inflammation the general symp- 
toms are those of pyogenic infection. 

The parts should be kept scrupulously clean, and on no account 
should squeezing of the breasts be permitted. They should be protected 



118 DISEASES OF THE NEWLY BORN 



by a cotton pad. If acute inflammation develops, it should be treated 
as a surgical affection. 



INTESTINAL OBSTRUCTION 

The most frequent causes of intestinal obstruction in the newly born 
are malformations of the intestine ; rarely it may be due to pressure from 
tumors, or from a persistent omphalomesenteric duct or artery. The 
various pathological conditions present in intestinal malformations are 
considered in the chapter on Diseases of the Intestines. The most com- 
mon seat of obstruction is at the anus, the bowel being normally formed 
throughout, lacking only the external orifice. The next most frequent 
condition is obstruction in the rectum, which may be due either to a 
membranous septum in the gut, or to obliteration of the tube for some 
distance. These rectal obstructions are readily recognized. By the 
examining finger or a bougie the lower limit of the obstruction can be 
made out, but there is no means by which the upper limit can be deter- 
mined except by opening the abdomen. When the obstruction is above 
the rectum, localization is more difficult; but the most frequent seat is 
the duodenum. Of 38 cases collected by Gaertner, the seat of obstruction 
was the duodenum in 19 cases, the jejunum in 3, the ileum in 11, the 
colon in 6, the ileum and colon in 1. There is often obstruction at more 
than one point. 

The symptoms vary with the seat and the degree of the obstruction. 
In atresia of the anus or rectum there is at first simply an absence of all 
discharges from the bowel. Later there is abdominal distention from 
dilatation of the sigmoid flexure and colon. After several days vomiting 
begins. If there is atresia of the duodenum or any part of the small 
intestine, vomiting begins early — usually by the second day of life — and 
it is persistent. Nothing is passed from the bowels after the first dark 
discharge of the contents of the colon, which is chiefly mucus. There is 
rapid asthenia, and death from inanition usually occurs in four or five 
days. The higher the obstruction the shorter the duration of life. If 
the condition is one of stenosis only, the symptoms are similar to those 
described but less severe, and life may be prolonged for several weeks, or 
even months. The constipation in these cases is not absolute. When the 
cause of obstruction is external pressure, the symptoms do not always 
begin immediately after birth. We once saw a child in whom nothing 
abnormal was noticed for the first three weeks, but at the end of that 
time there developed all the signs of acute intestinal obstruction. Lapa- 
rotomy revealed a loop of intestine constricted by a tiny cord, which was 
probably the remains of the omphalomesenteric duct. 



DIAPHRAGMATIC HEEXIA 



119 



Cases of imperforate anus and membranous septum in the rectum are 
readily relieved by proper surgical treatment. In the other varieties of 
obstruction, whether in the rectum, in the colon, or in the small intestine, 
although life may be prolonged by the formation of an artificial anus, 
the ultimate result is almost invariably fatal, death usually occurring 
from marasmus during the early weeks of life. 

DIAPHRAGMATIC HERNIA 

This is due to a congenital deficiency in the diaphragm, which is 
usually on the left side. Of 118 cases collected by Livingston, 83 were 
on the left side, 18 on the right, 4 were central, 2 were double, in 1 the 
diaphragm was absent. With small openings only a single coil of intes- 
tine, with large ones a considerable part of the abdominal contents, may 





Fig. 13, A. — Diaphragmatic Hernia of 
the Right Side, Posterior View. 
Child sixteen months old; died of 
pneumonia at three and a half years. 



Fig. 13, B. — The Same, Immediately 
after Administration of Bismuth 
in Suspension. Stomach in the right 
thoracic cavity. 



be found in the thorax. This causes displacement of the heart, usually 
to the right side, prevents the full expansion of the left lung, and if the 
deformity occurs early in intra-uterine life the lung may remain rudi- 
mentary. If a large deficiency exists, infants may live but a few hours; 
with smaller ones, life may be prolonged indefinitely. 

The symptoms noticed soon after birth are usually cyanosis, rapid 
respiration, a sunken abdomen, an overdistended chest, and dyspnea. 
Children often live but a few hours. In those who survive a longer time 



120 DISEASES OE THE NEWLY BORN 

dyspnea is generally the most prominent symptom. It may be constant, 
it may occur in severe paroxysms, or there may be attacks of cyanosis 
often of great severity, these being produced by an accumulation of gas 
in the stomach or the thoracic part of the intestine. Other symptoms 
may at times suggest intestinal obstruction. The physical signs vary 
much from time to time. Sometimes those of pneumothorax are present ; 
at others there is so much dulness with the feeble respiratory sounds, 
as to suggest fluid. The signs are usually upon the left side, with dis- 
placement of the heart to the right. A positive diagnosis can often be 
made by means of the X-ray after the administration of bismuth. (See 
Figs. 13, A, and 13, B.) The condition is not amenable to treatment. 



CONGENITAL STRIDOR 

This term has been given to a rather rare form of dyspnea seen in 
very young infants, beginning usually in the first days of life. Respira- 
tion is noisy and inspiration is accompanied by a marked croaking, or 
crowing sound, and with recession of the soft parts of the chest wall, 
which, especially at times of excitement, may be very great, yet there 
is no cyanosis and no subjective distress. In spite of the apparent diffi- 
culty of respiration the child seems comfortable. Expiration is usually 
easy and voice and cry are normal. The stridor diminishes when the 
child is very quiet but usually does not quite disappear even in sleep. 

The symptoms begin in most cases immediately after birth or during 
the first week or ten days of life. They may increase for three or four 
weeks, then remain about stationary until the sixth or eighth month; 
after which with the growth of the larynx the dyspnea and stridor 
steadily diminish. By the end of the second year it is usually gone or 
heard only on occasion. 

For our knowledge of this affection we are especially indebted to the 
observations of Thomson, of Edinburgh, who believes that the condition 
is primarily functional and due to a want of proper co-ordination of 
the respiratory muscles. Secondarily there is produced a folding of the 
epiglottis upon itself along the median line, so that its lateral borders 
approximate each other. In many of the cases reported^ however, the 
change in the larynx seems to be rather a malformation especially of. the 
epiglottis, which greatly narrows the superior opening of the larynx. 
Congenital stridor is favored by the soft collapsible character of the 
structures of the larynx in young infants and the strong suction force 
of inspiration. 

The prognosis in most of these cases is good, the chief dangers being 
from intercurrent disease or from bronchopneumonia. Considerable 



SCLEREMA 121 

deformity of the thorax ma) r be produced (pigeon breast) which may 
persist to later childhood. 

The diagnostic features of congenital stridor are the noisy respiration 
with marked inspiratory dyspnea and crowing, with the absence of dis- 
tress or subjective symptoms of any kind. It seems to be more frequent 
in delicate children. Conditions with which it may be confounded are 
papilloma of the larynx, laryngismus stridulus, catarrhal croup, and 
laryngeal spasm associated with adenoids. The first three of these are 
excluded by the history and by the absence of changes in the voice; 
the last one by the fact that the child is not a mouth breather, that the 
dyspnea, is not increased by closing the mouth. 

Congenital stridor is not amenable to special treatment. Should the 
dyspnea reach an alarming degree tracheotomy may be performed. The 
indications are to maintain the child's general nutrition and to protect 
him, so far as possible, from diseases of the upper respiratory tract. 



SCLEREMA 

Sclerema is a condition characterized by hardening of the skin and 
subcutaneous tissues. It may occur in circumscribed areas or extend over 
nearly the entire body. It affects infants who are very feeble and usually 
terminates fatally. Although sclerema is chiefly seen in the first days 
of life it is not limited to the newly born, but may occur at any time 
during the first few months. It is not to be confounded with edema of 
the newly born, with which condition it is, however, sometimes associated. 
From published reports it appears to be of not very infrequent occur- 
rence in Europe, chiefly in large foundling asylums. In America, 
sclerema is a rare disease. In the newly born, sclerema affects those 
who are premature or very feeble, sometimes those who are syphilitic. 
Later it may follow any condition leading to extreme exhaustion, espe- 
cially the different forms of diarrheal disease. 

The first thing to attract attention is usually the induration of the 
skin. It is often seen first in the calves or the thighs, sometimes first 
in the cheeks, but soon extends over the greater part of the body. It 
is especially marked in the cheeks, buttocks, and back, and regions 
where adipose tissue is abundant. It may affect the body uniformly 
or in circumscribed areas. The skin may be smooth or it may appear 
somewhat lobulated. The color is normal or slightly bluish, often 
tinged with yellow. The lips are blue, and the capillary circulation so 
feeble that after pressure upon the nails the blood returns slowly or not 
at all. The limbs are stiff and board-like. The skin is cold to the touch, 
and often the thermometer in the axilla will not rise above 90° F. In 



122 DISEASES OF THE NEWLY BORN 

one recorded case the axillary temperature was only 71° F. The general 
feeling of the body has been well likened to that of a half-frozen cadaver. 
The tongue and the mucous membrane of the mouth are cold; no radial 
pulse can be felt; the respiration is slow, irregular, embarrassed, and at 
times the movements of the thorax are scarcely perceptible. The cry is 
a feeble whine, scarcely audible. The duration of the disease is usually 
from three to four days. Death occurs slowly and quietly. If recovery 
takes place there is gradual improvement in the circulation and nutrition, 
and, later, a disappearance of the areas of induration. 

The causes of sclerema are general, the most important factors being 
loss of fluids, great feebleness with lowering of the body temperature, 
and, in consequence, hardening of the subcutaneous fat. There are no 
essential lesions in this disease. Atelectasis is often present, and may 
have something more than an accidental association, as incomplete aera- 
tion of the blood is no doubt a factor in the production of the symptoms. 
Microscopical examination in typical cases has shown the skin to be 
normal. 

The prognosis is very bad, because of the grave conditions of which it 
is the expression, but it is not invariably fatal. In its milder forms, 
where treatment is begun early, recovery may take place. The diagnosis 
is to be made from edema by the fact that there is no pitting upon 
pressure, by the rigidity of the body, and by the great reduction in the 
temperature. The most important thing in treatment is artificial heat; 
nothing but the incubator is efficient. In addition to this, care should 
be taken to promote the general nutrition by careful feeding and by all 
other means possible. 

INANITION FEVER 

The term inanition fever is not altogether a satisfactory one; but, 
until these cases are better understood, it is adopted because it empha- 
sizes the very close connection which exists between the rise of tempera- 
ture and the condition of inanition or starvation. Under this heading 
are included cases seen during the first five days of life — generally from 
the second to the fourth day — in which there is an elevation of tem- 
perature, apparently due to the fact that the infant gets very little, 
frequently nothing at all, from the breast at which he is being suckled. 
It is further characteristic of these cases that the temperature falls when 
the child is put upon a full breast, or when artificial feeding is begun, 
or even when water is administered, if freely given. Some have ascribed 
the symptoms to uric-acid infarction of the kidneys. 

So far as our knowledge goes, the first to call attention to this con- 
dition was McLane (New York), who in 1890 reported to one of the 



INANITION FEVER 123 

medical societies an extraordinary case of hyperpyrexia in a newly-born 
child. The infant was found on the sixth day with a temperature of 
106° F., near which point it had remained for three days. The child 
was being suckled at a breast which was found to be absolutely dry. 
A wet-nurse was procured, the temperature fell to normal in a few hours, 
and the child, which when first seen was apparently in a hopeless condi- 
tion, was soon perfectly well. 

Since that time very extensive observations, extending to upward of 
three thousand cases, have been made at the Sloane and the Xursery and 
Child's Hospitals, which have established the fact that a rise of tempera- 
ture to 102° or even 104° F. is quite common in newly-born infants dur- 
ing the first few days. This fever is accompanied by no evidences of local 
disease, and ceases in nursing infants with the establishment of the free 
secretion of milk. The fall in temperature is often rapid, dropping to 
the normal in a few hours after having continued for three or four days, 
and in a large number of cases it does not rise again. 

The following case is a fairly typical one of the moie severe form: 
The patient was the second child, the first having died at the age of ten 
days, from no disease, it was said, but simply from exhaustion. At birth 
the infant, a boy, weighed eight and a quarter pounds and was apparently 
vigorous. During the first forty-eight hours his loss in weight was five 
and a half ounces and his condition good. He was seen on the evening 
of the third day. In the preceding twenty-four hours he had lost eight 
ounces in weight, and the temperature had gradually risen, until at the 
time of our visit it was 102.8° F. The body was limp, the child making 
no resistance to examination. He cried with a feeble whine ; the restless- 
ness of the early part of the day having given place to complete apathy. 
The lips and skin were very dry, the fontanel sunken, the pulse weak. 
As the father, a physician, expressed it, "he had been wilting through 
the day like a flower in the sun." Although put to the breast regularly, 
the child had apparently obtained very little. It was, in fact, impossible 
to express any milk from the mother's breasts. Water was freely given 
and a wet-nurse secured in a few hours. The first milk was taken from 
the wet-nurse at 11 p.m., and the temperature, which fell gradually 
during the night, was normal the next morning and did not rise again. 
(See chart, Fig. 14.) During the succeeding four days the child gained 
eighteen ounces in weight, and at the end of a week was as well as an 
average infant of his age. 

The symptoms are so uniform and so characteristic that they make 
for these cases of fever a class by themselves. The frequency with which 
this is seen is shown by the following statistics: Among 200 infants 
taken successively at the Nursery and Child's Hospital, 20 had fever 
during the first five days, reaching 101° F. or over, which was not 



124 



DISEASES OF THE NEWLY BORN 



103 c 



102" 



101 c 



100 c 



explained by ordinary causes and followed the course above described. In 
500 successive children born at the Sloane Hospital, there were 135 with 
a similar fever. It was seen in vigorous infants as well as in those who 
were delicate. The usual duration of the fever was three days, the tem- 
perature generally touching the highest point upon the third or fourth 
day of life. In about two-thirds of the cases the temperature did not rise 
above 102° F. ; in 9 it was 104° F. or over, the highest recorded being 
106° F. The fall was generally quite abrupt, although not always so. 

Daily weighings, which were made 
in these cases, showed that the in- 
fants continued to lose weight 
while the fever continued, and that 
the loss almost invariably exceeded 
by several ounces that of the chil- 
dren who had no fever. The max- 
imum loss noted was twenty-eight 
ounces. In quite a large number 
of cases it exceeded twenty ounces. 
As a rule the infants began to gain 
in weight when the temperature 
remained at the normal point, but 
not until then. 

The symptoms presented by 
these infants were a hot, dry skin, 
Fig. 14,-Temperature Chart. Inanition marked restlessness, dry lips, and a 
Fever. disposition to suck vigorously any- 

thing within reach. With very 
high temperature there were considerable prostration and weakened 
pulse. In the less severe cases there were only crying and restlessness. 
The rapidity with which the symptoms disappeared when the children 
were wet-nursed or properly fed, was very striking. 

It is important that this fever should be recognized, because it gives 
at times the first warning of a condition which may prove fatal. The 
extra loss of ten or fifteen ounces in the first week is a serious handicap 
to newly-born infants, the effect of which may last for several weeks. 
The temperature of every child should be taken during the first week. 
All the usual local causes of fever are first to be excluded by a physical 
examination. This fever can hardly be confounded with that due to 
pyogenic infection, which rarely begins before the fifth or sixth day. 

The treatment is simple, viz., to give water regularly every two hours, 
in quantities up to an ounce at a time if required by the thirst of the 
child. This should be done in every case where the temperature reaches 
101° F. When the temperature does not at once begin to fall, the infant 



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INANITION FEVER 125 

should be put upon another breast or artificial feeding should be begun. 
Examination of the breasts from which the child has been nursing will 
usually reveal the fact that the secretion of milk is very scanty and often 
entirely absent. 

Such a fever we have occasionally seen in older infants, usually in 
those who are nursing dry breasts or where fluid food and water have 
been withheld because of some gastric disturbance. It yields as promptly 
to treatment as does the same condition in the newly born. 



SECTION II 
NUTRITION 

CHAPTER I 

Nutrition in its broadest sense is the most important branch of 
pediatrics. In no other field and at no other time of life does prophy- 
laxis give such results as in the conditions of nutrition in infancy. The 
largest part of the immense mortality of the first year is traceable 
directly to disorders of nutrition. The importance of correct ideas 
regarding this subject can hardly be overestimated. The problem is not 
simply to save life during the perilous first year, but to adopt those 
means which shall tend to healthy growth and normal development. 
The child must be fed so as to avoid not only the immediate dangers of 
acute indigestion, diarrhea, and marasmus, but the more remote ones of 
chronic indigestion, rickets, scurvy, and general malnutrition, since 
these conditions are the most important predisposing causes of acute 
disease in early life. 

One of the difficulties has always been that temporary success may 
mean ultimate failure. If the injurious effects of improper feeding were 
immediately manifest there would be very much less of it than exists 
at the present time. Many things are valuable as temporary foods, which 
when used permanently are injurious. No better illustration of this is 
seen than in the too exclusive use of the carbohydrate foods. Infants 
fed upon many of the proprietary foods often grow very fat, and for the 
time appear to be properly nourished. The effect of the absence from 
the diet of some of those elements which are of vital importance may not 
be evident for months. The physiological laws regarding the require- 
ments of the growing organism cannot be ignored without serious conse- 
quences, which will sooner or later be evident. Correct ideas of infant 
feeding are based upon a knowledge of these laws. An accurate under- 
standing of fundamental principles is essential to success and the 
vast majority of failures may be ascribed to ignorance or disregard of 
them. 

127 



128 NUTRITION 



THE FOOD CONSTITUENTS AND THE PURPOSES THEY SUBSERVE 

IN NUTRITION 

In infancy and childhood, as in adult life, the elements of the food 
are five in number : protein, fat, carbohydrates, mineral salts and water. 1 
The forms in which they must be furnished to the child, and the relative 
quantities in which they are demanded, are different from those required 
by the adult. One reason for this difference is the delicate structure of 
the organs of digestion in infancy, and their inability to assimilate cer- 
tain forms of food. Again, provision must be made not only for the 
natural waste of the body, but for its rapid growth, nearly trebling in 
size, as it does, during the first twelve months. 

Amount of Food Required,. — The attempt has been made to deter- 
mine accurately the amount of food which an infant should receive dur- 
ing the first year. The food of infants who were thriving satisfactorily 
has been measured, and many metabolism experiments have been carried 
out for the purpose of definitely settling this question. While all these 
observations have shed much light upon the subject we are not yet able 
to reduce to a mathematical formula the amount of food which shall be 
given to keep an infant in health and enable him to develop normally. 
As yet, the results of intelligent clinical observation of infants form our 
best guide as to food requirements. Individual infants, though they may 
all be equally healthy, differ very muchjn this respect, depending upon 
their weight, their size and also much upon their physical activity. One 
that is particularly active or restless requires more food than does one 
who is very quiet and lethargic. The size of the body, or the surface area, 
is doubtless of much more importance in estimating food requirements 
than the weight, but the latter is so much more easily determined that it 
has come into general use in estimating the amount of food to be given 
per diem. It is a matter of general agreement that the requirements of 
the infant, relatively to the weight, are greatest during the first months of 
life and become gradually less, so that by the end of the first year they 
are only about three-fourths as great as during the first month. Heubner 
placed the child's needs at 100 calories per kilo (45 per pound) during 
the first quarter year and at 70 per kilo (30 per pound) during the last 
quarter year. These figures have been much used as an arbitrary stand- 
ard, and indeed they do furnish an excellent starting point for the feed- 
ing of an individual child, but they can hardly do more. The subsequent 
variations in the amount of food must be decided by the child's demon- 

1 There are other substances whose presence in the food is vitally necessary 
for life, such, for instance, as the vitamins. They exist in most of the common 
articles of food. Their chemical composition is uncertain, Their absence pro- 
duces definite symptoms. 



THE FOOD CONSTITUENTS 129 

strated needs and his digestive capacity; but wide variations from these 
averages, whether above or below them, are usually found to be either 
inadequate or disturbing. Again, these amounts are designed for healthy 
infants with good digestion. Sick children, or those suffering from 
digestive disturbances^ must be fed according to the capacity of their 
digestion. The expression in calories of the energy value of the food does 
not imply that this is to be regarded as a method of feeding. It is only 
a method of stating the amount of food which a child is receiving, in a 
more accurate and scientific way than others that have been employed, 
e.g., the number of ounces given daily, which really represents only the 
volume of the food, or tells rather the amount of water in which the food 
is given. 

The calculation of the total food in terms of energy units is chiefly of 
assistance in enabling one to recognize readily whether an infant is 
receiving too much or too little food. 

In determining the calories of the food it is calculated that: 

1 gram of fat yields 9.3 calories 

1 " " carbohydrate " 4.1 " 
1 " " protein " 4.1 

Protein. — Protein is essential to life, since it is the only kind of food 
which is capable of replacing the continuous nitrogenous waste of the 
cells of the body upon which health depends. Protein is also indis- 
pensable for growth. In the adult only the requirements of repair are 
to be supplied. In the child a much larger amount is demanded to 
provide for growth. Without the aid either of the fats or the carbo- 
hydrates, protein may sustain life for a considerable time; but in so 
doing a great excess of such food is required. When fats and carbo- 
hydrates are added to the food much less protein is required to replace 
the nitrogenous waste. 

Of all the forms in which protein food may be furnished to the body, 
in proportion to its nitrogen content, milk taxes the digestive organs 
least. Furthermore, there is no other form of protein in which those 
amino-acids which have been shown to be essential for growth are so 
abundantly supplied as in milk. These facts are of great importance and 
indicate the superiority of milk as a food for infants, particularly during 
the first year. The protein of woman's milk is very readily digested. 
Regarding the protein of cow's milk there is no doubt that the view 
formerly held that it was difficult of digestion was erroneous. On the 
contrary, under most conditions it is digested and absorbed with facility. 
During most of the first year, milk furnishes all the protein that is 
needed for proper nutrition. But as cow's milk protein is low in certain 
important amino-acids, a larger amount of it musi he given than the 



130 NUTRITION 

protein contained in woman's milk, or growth will suffer. During the 
second year meat, eggs, etc., may add to the protein of the diet. 

The digestion of protein is begun in the stomach but is principally 
carried on in the intestines. The albumoses and peptones produced by 
gastric and pancreatic digestion are broken up as the result of the action 
of the erepsin of the intestinal juice into polypeptids and finally into 
amino-acids. It is as amino-acids that nearly all of the nitrogen is 
absorbed. In almost all circumstances, the nitrogen of the protein is 
well absorbed. The tendency to retain nitrogen is one of the striking 
attributes of the infant. He retains this if it is in any way possible and 
may continue to do so even when losing greatly in weight. This may be 
taken as an indication of the great efforts that the body makes to 
further growth. 

The nitrogen which is not retained is largely excreted by the urine. 
The nitrogen of the feces is relatively small in amount, is influenced 
somewhat by the kind of food and is in considerable part derived from 
the intestinal secretions which themselves contain a certain amount of 
protein. 

In artificial feeding it has been maintained that a large excess of 
nitrogenous products must be disposed of by digestion and elimination 
and that this taxes the organs of digestion and excretion. It may be said 
that there is at the present time no proof that milk protein even in con- 
siderable excess is dangerous to the welfare of the infant. 

The prolonged use of a diet in which the protein is insufficient in 
amount or defective in character produces a certain definite group of 
symptoms which are not always referred to their proper cause. In infants 
the most striking are slower growth, anemia, poor circulation, feeble mus- 
cular power, disinclination to exertion, and various functional nervous 
disturbances. Such children are often very fat. Vegetable proteins do 
not seem able permanently to take the place of animal proteins in the 
food of young infants for the reason that most of them are deficient in 
some of the essential amino-acids. Since in milk and in fact in almost 
all the foods of the infant a very constant relation exists between the 
protein and the salts, it is somewhat difficult to separate symptoms due 
to low protein from those due to low salts ; the two are often combined. 

The ingestion of casein in large amount produces in infants, large, 
dry, light colored stools, often of an alkaline reaction. They also con- 
tain a high proportion of mineral salts. With these stools there is usually 
constipation. While this effect in health is one not to be desired, it is 
decidedly advantageous in diarrhea to combat the fermentation produced 
by carbohydrates and fats. For this reason, as will be seen later, protein 
in large amount is a valuable therapeutic remedy for many intestinal 
conditions during infancy and childhood. 






THE FOOD CONSTITUENTS 131 

Fats. — Fats are a most important source of energy to the body, their 
caloric value being a little more than twice as great as that of either the 
carbohydrates or the protein. They save nitrogenous waste and increase 
the body weight. The large amount of fat stored up in the subcutaneous 
tissues in infancy is one of the best evidences of health. 

The amount of fat received by a breast-fed infant is relatively much 
greater than that given to adults in a normal diet. A well-nourished, 
nursing infant weighing fifteen pounds actually receives about one-half 
as much fat as is allowed in a ration for an adult doing moderate work, 
who weighs ten times as much. There can be no doubt that fat is bene- 
ficial for infants and that those who can take a reasonable amount of fat 
thrive better than those who can not. It is also plain that the one of the 
ingredients of cow's milk most difficult for the infant to digest is the fat. 

Fats may, for a considerable time, be largely replaced by the carbo- 
hydrates; but nutrition suffers if this substitution is complete or long 
continued. Fats are acted upon very slightly in the stomach, although 
they greatly retard the emptying of the stomach. Their digestion in the 
intestine is, under normal conditions, very complete, and only a small 
percentage of the fat passes through the intestine unchanged. Under 
normal conditions, from 80 to 90 per cent of the fat ingested is absorbed 
either as fatty acids or as soaps. No neutral fat can be absorbed. 

When the diet contains fat and protein in considerable quantity and 
is low in carbohydrate, stools are formed consisting largely of calcium 
and magnesium soaps, and the loss/ of these substances may even be so 
great that a negative balance of these minerals results. In certain 
circumstances, fats in the intestine may be decomposed and acids formed, 
but this rarely occurs unless carbohydrates in excess are also given. As 
a result of this fermentation, irritating products — chiefly the lower fatty 
acids — are formed, and these readily provoke diarrhea. In the diarrheal 
stook there may be sufficient potassium and sodium loss to bring about 
a negative balance of these minerals. The influence of the fat, therefore, 
upon the mineral balance is an important one. 

Carbohydrates. — Although, like the fats, these can not replace the 
nitrogenous waste of the body, they are important aids in sparing the 
protein, and in this respect they are even more valuable than the fats. 
The carbohydrates are partly converted into fat, and may thus increase 
the body weight. They are capable of replacing the fat-waste of the body. 

Carbohydrates are the most abundant of the solid elements of the 
food, although they form a smaller percentage of the entire quantity of 
food in infancy than in adult life. The soluble carbohydrates which are 
used as foods for infants are: milk sugar, cane sugar and mixtures of 
maltose and dextrin. Maltose in a pure form is not used on account of 
its cost and because it has no advantages. Mixtures containing maltose 



132 NUTRITION 

have distinct advantages in some circumstances. Since all sugars are 
finally converted into glucose, they are, to a certain extent, inter- 
changeable. Milk sugar has an advantage in not fermenting with the 
common varieties of yeast present in the stomach as do both maltose and 
cane sugar. * Except for this, there is not much to choose between milk 
sugar and cane sugar. Gain in weight is satisfactory with either, and 
they are equally safe. They have the same disadvantages and dangers in 
that they readily undergo fermentation in the intestine by the action of 
bacteria. As a result of this fermentation, lower fatty acids are formed 
not only from the sugar but also from the fats which are present in the 
food, with the result which has been described above under the fermen- 
tation due to excessive quantities of fat. 

The ability of the young infant to digest starches is relatively feeble, 
although this power does exist to some degree from birth ; but the greater 
part of the carbohydrates required should be furnished in the form of 
sugar. To infants of four months and over, starches may at times ad- 
vantageously be added to the diet, and after seven or eight months the 
quantity may be considerably increased. But in whatever form or quan- 
tity used thorough cooking is necessary. 

The advantages of the carbohydrates as foods depend upon the ease 
with which they are digested and absorbed. They are at a great dis- 
advantage on account of the readiness with which all of them, and espe- 
cially the sugars, undergo fermentation in different parts of the ali- 
mentary tract. The mixtures of maltose and dextrin, for some unex- 
plained reason, are often safer to give to children who have suffered from 
diarrhea. While they themselves have a tendency to cause rather loose, 
brownish stools, they do not so readily undergo excessive fermentation 
and may sometimes be given with safety when other sugars, especially 
lactose, would cause serious disturbances. 

A diet consisting too exclusively of carbohydrates often leads to a 
rapid increase in weight, but it is not accompanied by a proportionate 
increase in strength. Infants so fed have but little resistance, and many 
of them become rachitic. The easy digestion of foods consisting chiefly 
of soluble carbohydrates, such as sweetened condensed milk and the pro- 
prietary infant foods, and the rapidity with which children so fed gain 
in weight, lead to a great misapprehension in regard to their value as 
foods. The ultimate results of such one-sided feeding, if long continued, 
are almost invariably disastrous. 

In building up the cells of the body the protein is first in importance, 
but in the production of energy the fats and the carbohydrates have a 
greater value. Tn a proper diet all of these elements are represented. 

Mineral Salts. — The great importance of the mineral salts in the 
nutrition of infants and children has only recently been appreciated. 



THE FOOD CONSTITUENTS 133 

These salts are important not only for growth, bnt for all the physical 
and chemical processes which are carried on in the body. If they are 
not furnished in sufficient amount in the food, or if conditions exist in 
which their absorption, retention and utilization are interfered with, all 
the functions of the body are disturbed and life may be jeopardized. 
Except in the case of infants fed upon the proprietary foods, salts are 
very seldom lacking in the food. Those who receive woman's milk usually 
receive an adequate supply ; and those who are fed on cow's milk receive 
not only the salts required, but a very considerable excess of them, often 
two or three times the requirements of the child. This excess apparently 
does no harm, as it is either not absorbed or is excreted by the intestines 
or kidneys. The mineral salts form from 10 to 35 per cent of the dried 
matter of the normal stool. For perfect nutrition not only must all the 
mineral salts be furnished in the food but the other elements of the food 
must not have an injurious effect upon their retention. The chief dan- 
gers to the retention of sodium and 'potassium arise from fermentation 
of carbohydrates and fats in the intestine. Disturbances in the metab- 
olism of the salts are very frequent and are no doubt at the basis of many 
common nutritional disturbances of infancy. 

Water. — The food of all young mammals consists of from eighty to 
ninety per cent of water. This is needed for the solution of certain parts 
of the food, such as the sugar, the salts, and some of the protein, and for 
the suspension of other protein and the emulsified fat. All the food is 
thus dissolved or very finely divided so as to be more readily acted upon 
by the delicate digestive organs of the infant. Water is needed also in 
large quantities for the rapid elimination of the waste of the body: 

The amount of fluid required by the infant, in proportion to his size 
and weight, is much greater than that required by the adult. During 
early infancy an infant should receive daily an amount of fluid equal to 
about one-fifth his body weight. As it is practically impossible to give 
to a young infant any considerable part of this as water, this figure gives 
us an important guide as to the volume of the food to be given daily to 
an artificially-fed infant. The passage of a large amount of urine of 
low specific gravity is one of the physiological conditions of infancy and 
sufficient water must be furnished to the infant to make this possible. 
It is not therefore a matter of indifference whether we give the daily 
amount of food with twenty or with thirty-five ounces of water. After 
six months fluids can be given in the form of fruit juices, broth, etc., and, 
besides, the older infant will usually take water in proper amount without 
difficulty, so that the same relation of the volume of food to the body 
weight need not be maintained. Of the water received it is estimated 
that 59 per cent is eliminated by the kidneys; 33 per cent by the lungs, 
6 per cent by the intestines, and that from 1 to 2 per cent is retained. 



134 NUTRITION 

CHAPTEE II 
THE INFANT'S DIETARY 

WOMAN'S MILK 

Woman's milk is the ideal infant-food. A knowledge of its character, 
composition, and variations is indispensable, for upon this knowledge are 
based all our substitutes for woman's milk when this can not be obtained. 

Woman's milk is a secretion of the mammary glands and not a mere 
transudation from the blood-vessels ; although under abnormal conditions 
it may partake more of the character of a transudation than a secretion. 
A few drops may be squeezed from the breasts before parturition; gen- 
erally speaking, however, it is only present after delivery. During the 
first two days the secretion is scanty. Usually upon the third or fourth 
day it becomes well established, although it may be delayed many days 
longer and yet become abundant. During the period of lactation, milk 
is constantly formed in the mammary glands, but the process is more 
active while the child is at the breast. 

Physical Characters. — Woman's milk is of a bluish-white color and 
quite sweet to the taste. When freshly drawn its reaction is amphoteric 
to litmus, or slightly acid to phenoiphthalein. The specific gravity varies 
between 1.026 and 1.036, the average being 1.031 at 60° F. On the 
addition of acetic acid only a slight coagulation is seen, this being in 
the form of small flocculi, and never in large masses as is the case 
in cow's milk. Microscopically, there are seen great numbers of 
fat-globules nearly uniform in size and some granular matter. Oc- 
casionally there are present epithelial cells from the milk-ducts or from 
the nipple. 

Early Milk. — The secretion of the early days of lactation to which 
the term "colostrum" has been given, differs quite markedly from the 
later milk. It is of a deep-yellow color, which is chiefly due to the colos- 
trum-corpuscles. It has a specific gravity of 1.030 to 1.035, a strongly 
alkaline reaction, and is coagulated into solid masses by heat, and some- 
times the milk of the first days coagulates spontaneously. It is very rich 
in protein and in salts. Microscopically the fat-globules are of unequal 
size, and there are present large numbers of granular bodies known as 
colostrum-corpuscles. These are four or five times the size of the milk- 
globules, and they are probably leucocytes in which are contained numer- 
ous fat granules. They are much larger than ordinary leucoc} T tes and 
are nucleated. 

The colostrum-corpuscles are very abundant during the first few days, 



WOMAN'S MILK 135 

but under normal conditions they are not found after the tenth or twelfth 
day. 

Composition of Colostrum 

First and Two to 

second days ten days 

Fat 2.38 3.00 

Sugar 3.38 7.50 

Protein '. . . 8.60 2.25 

Ash 0.37 0.30 

Water 85.27 86.95 



100.00 100.00 

The characteristic features of colostrum milk continue for a period 
varying from five to ten days; but it is not until about the end of the 
first month that the milk assumes its stable or "mature" character. The 
milk of the intermediate period is sometimes spoken of as "transition 
milk." It shows a marked but gradual fall in the protein and ash, and 
a moderate rise in the fat and sugar until the composition of mature milk 
is reached; after this time no constant or regular changes are seen in the 
proportion of the different constituents until near the close of lactation. 

Daily Quantity. — Exact information upon this point is difficult to 
obtain. There are recorded, however, extended observations made with 
great care upon a number of cases. The eight cases quoted below x were 

1 Haehner's cases (Jahrb. f. Kinderh., xv, 23; xxi, 314). Case I. Female; 
birth-weight, 7 pounds 14 ounces (3,100 grams). First week, lost 1 2 ounce (45 
grams); after this gained steadily during the twenty-three weeks of observation; 
from second to ninth week, average weekly gain 8 ounces (241 grams) ; from 
tenth to eighteenth week, average gain 41 ounces (138 grams) ; from nineteenth 
to twenty-third week, average gain 4 ounces (130 grams) ; weight at the end of 
twenty-third week, 14 pounds (6,690 grams). 

Case II. Male; birth-weight 62 pounds (2,950 grams). Loss, first week, 3 
ounces (90 grams) ; after this gained steadily during the eleven weeks of obser- 
vation; from second to eleventh week, average weekly gain 7h ounces (214 
grams); weight at end of eleventh week, 11 pounds 2 ounces (5,045 grams). 

Case III. Female; birth-weight 3 pounds 9 ounces (1,620 grams). Gain, 
first week, 1 J ounce (45 grams) ; during the succeeding twenty-one weeks of 
observation, average weekly gain 5 ounces (141 grams); weight at the end of 
twenty-second week, 10 pounds 3 ounces (4,620 grams). 

Laure's case (These, Paris, 1889). Female; birth-weight 8 pounds 13 ounces 
(4,000 grams) ; loss, first week, 8 ounces (225 grams) ; after this gained steadily 
during the nine weeks of observation, on an average 9* ounces (268 grams) 
weekly; at the end of ninth week, weight 13 pounds 3i ounces (6,000 grams). 

Ahlfeld's case (Deutsch. Ztschr. f. Prakt. Med., 1878). Birth-weight 7 pounds 
14 ounces (3,100 grams). Observations continued from fourth to thirtieth week. 
During first ten weeks, average weekly gain 51 ounces (161 grams); from 
eleventh to twentieth week, 7i ounces (214 grams) ; from twenty-first to thirtieth 



136 



NUTRITION 



all healthy infants, nursing exclusively and gaining steadily in weight. 
From these observations, and others less extended, the average daily 
quantity of milk secreted under normal conditions of health may be 
assumed to be pretty nearly as follows : 

Approximately. 

At the end of the first week 10 to 16 oz. (300 to 500 coin.) 

During the second week 13 to 18 oz. (400 to 550 c.cm.) 

During the third week 14 to 24 oz. (430 to 720 c.cm.) 

During the fourth week 16 to 26 oz. (500 to 800 c.cm.) 

From the fifth to the thirteenth week.. 20 to 34 oz. (600 to 1,030 c.cm.) 

From the fourth to the sixth month. . . 24 to 38 oz. (720 to 1,150 c.cm.) 

From the sixth to the ninth month 30 to 40 oz. (900 to 1,220 c.cm.) 

It will be noted that the amount increases very rapidly up to about 
the eighth week, and after this much more slowly. The amount of milk 

varies also with the demands of the child in a very striking way. 1 The 

— — — 

week, 6 ounces (168 grams) ; at the end of the thirtieth week, weight 18 pounds 
9i ounces (8,435 grams). 

Feer (Jahrb. f. Kinderh., xlii, 195). Three cases. 

In all these cases the amount of milk was determined by weighing the infant 
both before and after every nursing during the entire period of observation. 
The following table gives in a condensed form the daily quantity of milk in 
these cases: 



Time. 



Haehner's 
1st Case. 



Haehner's 
2d Case. 



Haehner's 
3d Case. 



Laure's 
Case. 



Ahlfeld's 
Case. 



Feer's 
3 Cases. 
Average. 



1st day 

2d day 

3d day 

4th day 

5th day 

6th day 

7th day 

Average 2d week 

Average 3d week 

Average 4th week 

Average 5th week ..... 

Average 6th week 

Average 7th week 

Average 8th week 

Average 9th week 

Average 10th to 13th week 
Average 14th to 17th week 
Average 18th to 23d week 
Average 24th to 30th week 



Grams. 
20 
176 
265 
420 
360 
374 
423 
497 
550 
594 
663 
740 
880 
835 
766 
796 
807 
870 



Grams. 

75 
135 
325 
295 
290 
340 
350 
423 
468 
531 
561 
661 
681 
730 
665 



Grams. 

20 
45 
70 
99 
124 
136 
156 
229 
314 
379 
447 
472 
525 
568 
584 
600 
673 
709 



Grams. 



125 

222 

400 

475 

500 

556 

730 

810 

944 

978 

1,038 

1,024 

1,085 



Grams. 



576 
655 
791 
811 
845 
810 
869 
983 
1,029 
1,145 



Grams. 



256 

(average 
1st week) 



610 
667 
753 
802 
815 
820 
795 
845 
919 
1,002 



1 There are a number of recorded instances in which the amount of milk se- 
creted has been quite extraordinary — in some cases as much as four quarts daily. 
Lactation in exceptional instances also is unduly prolonged. We know of one 
well authenticated American case in which it continued for seven years. Among 
the Japanese it is frequent for it to continue up to three or four years. 
Among the Hottentots and other savage races lactation may be prolonged until 
the sixth or seventh year. 



WOMAN'S MILK 137 

quantities mentioned can not be taken as an absolute guide to the 
amount of food to be given to bottle-fed infants. Breast milk contains 
an average of twelve per cent solids ; while the modification of cow's milk 
best suited to the early months seldom has more than from nine to 
eleven per cent solids. For this period, therefore, somewhat larger quan- 
tities are needed than of breast milk. 

A comparison of the daily amount of milk taken with the weight of 
the child at the different periods, showed that both during the early and 
the later periods the larger children took not only more milk, but con- 
siderably more in proportion to their body weight than did the smaller 
ones. This harmonizes with the common observation that small children 
are much more likely to be overfed than large ones. 

The average quantity taken at one nursing by five of the children 
previously mentioned was as follows : 

Approximately. 

During the first week « f to 1£ oz. (18 to 45 c.cm.) 

During the second week 1 to 3 oz. (30 to 90 c.cm.) 

During the third week 1§ to 4 oz. (45 to 120 c.cm.) 

During the fourth week 1| to 4| oz. (45 to 140 c.cm.) 

From the fifth to the seventh week 2 to 5 oz. (60 to 150 c.cm.) 

From the eighth to the eleventh week. . . 2\ to 5| oz. (75 to 160 c.cm.) 

During the fourth month 3 to 6 oz. (90 to 180 c.cm.) 

During the fifth month 3| to 6| oz. (110 to 200 c.cm.) 

During the sixth month 4 to 7 oz. (120 to 220 c.cm.) 

Between the limits mentioned the greater number of cases will un- 
doubtedly fall. The amount taken at one time is, however, modified by 
the frequency of nursing, and is therefore not so good a guide to the 
amount of food required, as is the quantity taken in twenty-four hours. 

Composition. — According to the analyses of Pfeiffer, Koenig, Leeds, 
Harrington, Adriance, Courtney and Fales and others, the composition 
of human milk is as follows: 





Normal Average 
(Mature Milk) 


Common Healthy 
Variations. 


Fat 


Per cent 

3.50 
7.50 
1.25 
0.20 

87.55 


Per cent 

3.00 to 5.00 


Sugar 


6.50 " 8.00 


Protein 

Ash 


1.00 " 2.00 
0.18 " 0.25 


Water 


89.32 " 84.75 








100.00 


100.00 100.00 



In the older analyses the percentage of protein was almost invariably 
made too high and the sugar too low. After the first month there are 
no regular changes in composition until near the end of lactation. This 
is a point to be borne in mind in the selection of wet-nurses. 



138 NUTRITION 

Milk also contains certain natural ferments which, though little 
understood, are believed to have a function in digestion. 

Protein. — The important forms of protein are casein and lactalbu- 
min; several others, lactogiobulin, lactoprotein and nuclein are also de- 
scribed. The casein is in suspension by virtue of the presence of calcium 
phosphate in the milk, with which it is probably in combination. It 
coagulates only slightly with rennet, while acetic acid produces a loose 
rlocculent precipitate. The lactalbumin resembles the serum-albumin of 
the blood. In woman's milk it is nearly twice as abundant as casein. 
Its proportion to casein is nearly twelve times as great as in cow's 
milk. 

The total protein of normal mature milk is usually between 1.0 and 
1.5 per cent. In abnormal specimens the variations are from 0.7 to 3.5 
per cent. The total protein is highest in the colostrum period; it falls 
steadily to the latter part of the first month. After this time, during 
the mature period, the variations are slight, but it tends to fall slowly. 
Toward the end of lactation the proportion of protein falls quite rapidly. 

Fat. — This exists in the form of minute globules, which are held in a 
state of permanent emulsion by the albuminous solution in which they are 
suspended. The fat of woman's milk is chiefly made up of the neutral 
fats — palmitin, myristin, stearin and olein; the last mentioned predom- 
inating. There are also small quantities of free fatty acids, but these 
are much less in amount than in cow's milk. The fat of woman's milk 
is relatively low in volatile fatty acids, compared with that of cow's milk. 
The proportion of fat is subject to even wider variations than is that of 
the protein, 3.5 per cent being taken as the normal average. In a series 
of thirty-four analyses the fat varied between 1.12 and 6.66 per cent. The 
highest percentage we have known was 10.91. In forty-three analyses 
by Leeds, the variations were between 2.11 and 6.89 per cent. The pro- 
portion is very little affected by the period of lactation. 

Sugar. — The sugar is in solution. Its proportion is more nearly con- 
stant under all conditions than any other constituent of milk. The 
ordinary variations are usually within the limits of 6.5 and 8 per cent. 

Ash. — The average proportion of inorganic salts is 0.20 per cent, or 
a little more than one-fourth that of cow's milk. The percentage com- 
position of the ash as compared with that of cow's milk is given in a 
subsequent chapter. 

With the exception of calcium phosphate nearly all the salts are in 
solution. The milk of the first few days is very rich in salts, chiefly owing 
to the large proportion of sodium and potassium chlorid; after the first 
month the normal variations 1 are slight and inconstant. 

1 From thirty-eight analyses by Courtney and Fales at the Babies' Hos- 
pital, the following average figures were obtained of the composition of the 



WOMAN'S MILK 



139 





The Examination of Milk. — The exact composition of human milk is 
to be determined only by a complete chemical analysis. Many variations 
in composition the physician may readily ascertain for himself by simple 
methods. 

The quantity of milk secreted by 
the breasts may be estimated by the 
quantity which may be drawn by a 
breast-pump, although this is not a 
very reliable test. If the child 
nurses habitually thirty or forty 
minutes, the probabilities are very 
strong that the milk is scanty. If 
the breasts at nursing time are full, 
hard, and tense, the supply is prob- 
ably abundant, If the breasts are 
soft and flabby, and appear to fill 
only while the child is nursing, it is 
almost certain that the quantity is 
small. The only really reliable test 
is weighing the infant just before 
and after nursing, upon an accurate 
pair of scales sufficiently sensitive to 
indicate half-ounces. This should 
be repeated several times in the day. 

The reaction of woman's milk 
even when freshly drawn is rarely 
alkaline, being amphoteric to litmus, 
or slightly acid to phenolphthalein. 

The specific gravity may be taken 
with any small hydrometer graduated from 1.010 to 1.040 (Fig. 15, A). 
The specific gravity is lowered by the fat, but increased by the other 
solids. An ordinary urinometer will answer every purpose, the only 

ash of woman's milk at the different periods of lactation. (Amer. Jour. Diseases 
of Children, Oct, 1915.) 



2E 



B 



Fig. 15. — Apparatus for Examination 
of Woman's Milk. The authors' 
lactometer and cream-gauge. 1 



Period 


No. of 

Analyses 


Total 
Ash 


CaO 


MgO 


P2O5 


Na 2 


K2O 


CI 


Colostrum (1-12 davs) 


5 
6 
9 
8 
10 


.3077 
.2407 
. 2056 
. 2069 

.1978 


.0446 
.0409 
.0486 
.0458 
.0390 


.0101 
.0057 
.0082 
.0074 
.0070 


.0410 
.0404 
.0342 
.0345 
.0304 


.0453 
.0255 

.0154 
.0132 

.0145 


.0938 
.0709 
.0539 
.0609 

().")/ 5 


.0568 


Transition (12-30 days) 

Early mature (1-4 months) 

Middle mature (4-9 months) .... 
Late milk (10-20 months) 


.0580 
.0351 
.0358 
.0442 



*The authors' apparatus may be obtained from Eimer & Amend, Eighteenth 
Street and Third Avenue, New York. 



140 



NUTRITION 



<&> 




difficulty being the quantity which is required to float the instrument. 
Microscopical Examination. — The microscope may reveal the pres; 
ence of fat globules, colostrum corpuscles, blood, pus, epithelium, and 
granular matter. Colostrum corpuscles are abnormal after the twelfth 
day; pus and blood are always abnormal. The presence of any of these 
elements necessitates the suspension of nursing, at least temporarily. 
But little importance can be attached to the size and appearance of the 
fat globules as affecting the nutritive properties of the milk. 

The Determination of Fat. — The simplest method is by the cream- 
gauge (Fig. 15, B). Its results are only approximate, but in most cases 

sufficiently accurate for clinical purposes. 
The tube is filled to the zero mark with 
fresh milk, which stands, corked, at room 
temperature for twenty-four hours, when 
the percentage of cream is read off. The 
ratio of this to the fat is approximately 
five to three; thus 5 per cent cream indi- 
cates 3 per cent fat, etc. 

For an accurate determination the best 
ready method is the Babcock test, which 
requires 20 c.c. of milk, or the modifica- 
tion by Lewi 1 of the Leffman and Beam 
test for cow's milk. This requires special 
tubes. 

Sugar. — The proportion of 
varies so little that it may 
clinical examinations. 

Protein. — Clinical methods for the es- 

Babcock's tube for cow's milk; ,• i- j. n j_ • " ■ •• 

B, Lewi's modification for timation of the protein are not very sales- 
woman's milk. factory. 2 We may also form some idea of 

the protein from a knowledge of the spe- 

1 Lewi's method is as follows: 

(1) Place in the milk flask 2.92 c.c. of woman's milk measured in a special 
graduated pipette; (2) carefully rinse the pipette and add the same quantity 
of sulphuric acid C. P. of specific gravity 1.830. The acid should be added 
slowly, and mixed with the milk by gently rotating the flask. The color turns 
to a very dark brown from the oxidation of the sugar and protein; (3) now 
add 0.6 c.c. of a mixture of equal parts of fusel oil and strong hydrochloric acid; 
(4) add sufficient of a mixture of the same sulphuric acid and water, equal 
parts, to bring the level of the fluid well up into the neck of the flask; (5) 
centrifuge for three or four minutes. The percentage of fat is now read off, 
each one-tenth gradation in the neck of the flask representing 0.3 per cent 
of fat in the specimen of milk. 

2 The one giving the best results is that in which the protein is precipitated 
by a solution of phosphotungstic and hydrochloric acids in the Esbach tube, the 




sugar 
be ignored in 



Fig. 16. — Tubes for Determin- 
ing the Fat in Milk. A, 



WOMAN'S MILK 



141 



cific gravity and the percentage of fat, if we regard the sugar and salts 
a,s constant, or so nea*rly so as not to affect the specific gravity. We may 
thus determine whether it is greatly in excess or very low, which, after 
all, is the important thing. The specific gravity will then vary directly 
with the proportion of protein, and inversely with the proportion of fat, 
i. e., high protein, high specific gravity; high fat, low specific gravity. 
The application of this principle will be seen by reference to the accom- 
panying table. 

Woman s Milk 





Specific gravity — 70° F. 


Cream — 24 hours. 


Protein (estimated). 


Average 


1.031 


7% 


1.25% 


Normal variations 


1.028-1.029 


8%-12% 


Normal (rich milk) 


Normal variations 


1.032 


5%-6% 


Normal (fair milk) 


Abn'l variations . 


Low (below 1 . 028) 


High (above 10%) 


Normal or slightly below 


Abn'l variations . 


Low (below 1 . 028) 


Low (below 5%) 


Very low (very poor milk) 


Abn'l variations . 


High (above 1 . 032) 


High 


Very high (very rich milk) 


Abn'l variations . 


High (above 1.032) 


Low 


Normal (or nearly so) 



A specimen taken for examination should be either the middle portion 
of the milk — i. e., after nursing two or three minutes — or, better, the 
entire quantity from one breast. The first milk is slightly richer in 
protein and much poorer in fat. The last drawn from the breasts is lower 
in protein and much higher in fat. The following analyses from Forster 
illustrate these differences : 





First Portion. 


Second Portion. 


Third Portion. 


Fat 


Per cent 

1.71 

1.13 


Per cent 

2.77 
0.94 


Per cent 

5.51 


Protein 


0.71 







Conditions Affecting the Composition of Woman's Milk. — The Age of 

the Nurse. — This has no constant influence. Other things being equal, 
the milk of very young women, and also of those over thirty-five years 
of age, is likely to be lower in fat than that of women between twenty 
and thirty-five years. 

Number of Pregnancies. — Adriance found that the average milk of 
23 primiparae and 23 multiparae, both taken at the third month, showed 
the following differences: The milk of the primiparae averaged higher 
in fat and in protein, but a little lower in sugar. 

Acute Illness. — In the majority of cases of acute illness of a minor 
character and of short duration there is no perceptible effect upon the 

percentages being read off after standing twenty-four hours. For description see 
Boggs, Johns Hopkins' Hospital Bulletin, No. 187, October, 1906. 



142 NUTRITION 

milk. In the acute febrile diseases of a severe type the quantity of milk 
is reduced, the fat is low, and the protein is apt to be high. In septic 
conditions bacteria may appear in the milk. 

Menstruation. — The effect of this is exceedingly variable, depending 
much upon the individual and the ease of menstruation. The most 
frequent changes noted are diminution in the quantity and a lower fat 
with the protein sometimes increased. 

From observations upon 685 cases, Meyer noted disturbances in the 
child in over one-half the number. Our own experience accords rather 
with that of Pfeiffer and Schlichter, who consider it quite exceptional 
for the child to be visibly affected. Schlichter made observations upon 
infants during 233 menstrual days, noting the condition of the stools 
and digestion both before and after menstruation. In ninety per cent of 
the cases there was no perceptible influence. In only eight per cent were 
the stools bad, and in only three per cent was there disturbance of the 
stomach with vomiting. It is safe to say that the changes in milk accom- 
panying menstruation are not uniform, and that in very many cases none 
of importance are produced. 

Diet. — The composition of the milk is not so much influenced by diet 
as was formerly believed to be the case. The milk of an under-nourished 
woman is likely to be poor both in fat and protein. Sufficient food causes 
an increase in these substances. It is doubtful if the amount of fat can 
be further influenced by feeding either fat or carbohydrate, though by 
some authors it has been claimed that this could be done. Diet has a 
similar influence upon the quantity of protein. The amount of sugar is 
nearly constant under almost all circumstances. It is probably true that 
when the quantity of protein and fat are high they may be somewhat 
reduced by exercise and taking less food, but not to a marked extent 
unless under-nourishment had been present. All fluids tend to increase 
the quantity of milk. 

The nursing woman should have a generous diet of simple food, and 
should drink largely of milk or gruels made with milk. The diet should 
be a varied one, not excessive in nitrogenous food nor in vegetables. 
Salads and highly seasoned dishes should be avoided, not so much be- 
cause they upset the child, although this may happen, as because they 
are likely to disturb the digestion of the nurse. Nearly all the common 
vegetables and sweet fruits in season may be allowed in moderation. 
Strong tea and coffee should be prohibited, although weak tea or coffee 
may be allowed, each but once a day. Cocoa is not objectionable. In 
addition to her regular meals the nurse should have milk or gruel at 
bedtime. The diet should in all cases be adapted to her digestion. The 
bowels should move daily, by the use of laxatives if necessary. Great 
harm often results from overfeeding with its consequent indigestion. 



WOMAN'S MILK 143 

Alcoholic Beverages. — With many women the use of malted liquors — 
ale, beer, etc. — increases the quantity of milk and the proportion of fat; 
but with many others their only effect is to fatten the nurse, often to a 
striking degree. The effect of spirits upon the quantity and composition 
of the milk is less marked, but along similar lines. Unless taken in large 
amounts by the mother, alcohol does not appear in her milk, and there is 
no sufficient evidence that in usual amounts it has any deleterious effect 
upon the milk ; but the general use by nursing women of alcoholic bever- 
ages in any form is to be condemned. There are in most cases much bet- 
ter means of improving the milk than by ale, beer or whisky ; they should 
be recommended by the physician to nursing women with the greatest dis- 
crimination. The danger of the formation of the alcoholic habit is too 
great to be passed over lightly. 

Drugs. — The elimination of drugs through the milk is somewhat un- 
certain and variable; few of those popularly supposed to affect the child 
through the milk really do so. Given in full doses, belladonna regularly 
appears in the milk. Opium does not do so constantly; but when the 
milk is poor, enough may be excreted to produce serious symptoms. The 
iodids and bromids when long administered may be eliminated in suf- 
ficient quantity to produce their constitutional effects in the child. Mer- 
cury does not appear regularly, but only after prolonged use, and then 
in variable quantity. Most of the saline cathartics, arsenic, and the 
salicylates are occasionally found in the milk sometimes in quantities 
sufficient to produce symptoms in the nursing child. 

Pregnancy. — The milk of a nursing woman who has become preg- 
nant is generally scanty and poor in quality, especially in fat. The 
milk of a woman suffering from the toxemia of pregnancy is toxic 
to her infant. Fatal consequences have not infrequently followed put- 
ting an infant to the breast shortly after eclamptic attacks in the 
mother. 

Bacteria. — Under normal conditions woman's milk may contain a 
few bacteria. They are chiefly cocci derived from the external milk ducts 
and are of no importance. In suppurative inflammation of the mam- 
mary gland, numerous bacteria may be found in the milk ; also in some 
cases of puerperal sepsis. Tubercle bacilli have been demonstrated by 
Roger and Garnier in the milk of a woman with advanced tuberculosis, 
but ordinarily they are not present unless the gland is the seat of the 
disease. 

The Elimination of Antitoxin and Other Protective Substances by the 
Milk. — The immunity of nursing infants to most of the contagious dis- 
eases has long been noted, but until recently little understood. Animal 
experiments have demonstrated the constant presence of diphtheria an- 
titoxin in the milk of immunized animals. The Widal reaction has been 



144 NUTRITION 

obtained with the milk of mothers suffering from typhoid and with the 
blood of their healthy nursing infants. 

Nervous Impressions. — The effect of the nervous condition of a 
woman upon her milk secretion is very striking, and much more im- 
portant than the diet. Both the quantity and the composition of the 
milk are markedly changed by many different nervous impressions. 
Fright, grief, passion, excessive sexual indulgence, or any great excite- 
ment may entirely arrest the secretion, or if not arrested the milk may 
be so altered in composition as to make the child acutely ill. Worry, 
anxiety, fatigue, intense or prolonged nervous strain may so alter the 
milk as to cause it to disagree with a child who had previously thrived 
well upon it, or they may greatly diminish and sometimes even arrest 
the secretion. It is the nervous condition of the mother more than 
anything else which determines her success or failure as a nurse. If 
a mother would nurse successfully, she must have plenty of rest and 
sleep, moderate exercise, keep her mind free from unnecessary worries, 
avoid social engagements, and lead a simple, regular, natural life. Unless 
she can and will do this successful nursing can hardly be expected. 

The nature of the changes produced in milk by nervous disturbances 
in the mother are as yet little understood. Some infants are so pro- 
foundly affected as to suggest the development of toxic substances in the 
milk. The milk of the tired and worried mother is nearly always low 
in fat, while the protein is usually high, and possibly there are other 
changes as yet unknown. 

COW'S MILK 

Cow's milk being our main reliance in the artificial feeding of infants 
and the staple food of nearly all young children, it follows that every- 
thing relating to its production and handling is important. For fuller 
information than it is possible to give here the reader is referred to 
special works upon the subject. 1 

The essential conditions to be fulfilled in cow's milk which is to 
be used as a food for infants and young children are: (1) Freshness; 
(2) it should contain no preservatives; (3) it should be from healthy 
animals, free from tuberculous or other taint; (4) it should be clean; 
( 5 ) it should not be skimmed or otherwise falsified ; ( 6 ) it should con- 

1 Convenient works for a physician's use are Richmond's Dairy Chemistry ; 
Aikman's Milk, Its Nature and Composition, Block, London; Russell's Outlines 
of Dairy Bacteriology; Belcher's Clean Milk, Hardy Publishing Co., New York; 
Pearsons' Jensen's Milk Hygiene; Milk and Its Relation to Public Health, 
Bulletin 56, U. S. Public Health and Marine-Hospital Service; The Milk 
Question, M. J. Rosenau. 



COW'S MILK 145 

tain no pathogenic organisms; (7) the number of other organisms should 
not be excessive. It is also desirable for purposes of infant feeding that 
the composition of the milk, particularly the percentage of fat, should v 
be known, and that the milk should be as nearly uniform as possible from 
day to day and at different seasons of the year. Mixed or herd milk is 
therefore to be preferred to that from a single animal, since it is subject 
to fewer variations. The common varieties or "grade cows" should be 
chosen rather than highly bred animals, if for no other reason, because 
they are more hardy, less subject to disease, and less susceptible to other 
influences which might affect the milk. 

As ordinarily handled, milk should if possible be used before it is 
twenty-four hours old; after this time changes occur very rapidly, and 
such milk can not in summer be used with safety for infants. Milk 
may be safe for a longer time provided special precautions are taken 
in producing and handling it, and special care in keeping it constantly 
at a temperature below 50° F. 

Preservatives are sometimes added, particularly in hot weather, by 
unscrupulous dealers to retard the souring of milk, in order thereby to 
avoid the necessity and expense of proper icing. Formerly boric or sali- 
cylic acid was, and recently formaldehyd has been largely employed for 
this purpose. 

Microorganisms in Milk. — Most of the common bacteria grow readily 
in milk, and the conditions under which it is produced and handled 
render it liable to contamination in many ways. 

1. Disease in the Cow. — From disease of the udder streptococci or 
other pyogenic germs may enter the milk in such numbers as to excite 
acute gastro-enteritis in a child, but the particular danger under such 
circumstances is "septic sore throat." Within the last few years several 
severe epidemics of this dangerous disease have been reported. A number 
of these have been traced to herds that have included one or more animals 
with septic infection of the udder. Other diseases which may be com- 
municated from the cow are tuberculosis, anthrax, and the foot-and- 
mouth disease. Veterinarians differ much in their estimates of the 
amount of tuberculosis among cattle, the estimates range from 3 to 25 per 
cent. It is the general opinion that it is on the increase, though this may 
only mean that the disease is now more often recognized. Of the cattle 
slaughtered in London, 25 per cent are stated to be tuberculous. Unless 
the process is advanced or the udder is the seat of disease, tubercle bacilli 
are usually absent from the milk. Xevertheless tubercle bacilli are fre- 
quently found in small numbers in ordinary market milk. In 107 unse- 
lected specimens of milk sold from cans in New York City, Hess found 
tubercle bacilli in 17, or 16 per cent. Rabinowitch and Kempner in 25 
similar examinations in Berlin found tubercle bacilli in 7, or 28 per 



146 NUTRITION 

cent. Macfadyen in London found, in 77 samples of milk, tubercle 
bacilli present in 17, or 22 per cent. These figures may probably be 
taken to represent average conditions in large cities. But the dangers 
from milk are not quite so great as would appear from these findings, 
for in many of the cases the number of bacilli is very small and only 
discovered by animal inoculations. 

For reasons given elsewhere (vide Tuberculosis), we can not believe 
the danger of acquiring tuberculosis through milk as great as many 
have represented; yet milk must be regarded as one of the sources of 
tuberculous infection. The sale of milk from cows showing evidence 
of tuberculosis upon physical examination, and from those having tuber- 
culosis of the udder should not be permitted; also the milk of every 
cow which reacts to the tuberculin test unless pasteurized. 

2. Specific Pathogenic Organisms Accidentally Gaining Access to 
Milk. — The role of milk in the spread of infectious disease may be ap- 
preciated by the fact that in 1900 Kober was able to find records of 330 
outbreaks which were traced to it. The disease most frequently com- 
municated in this way is typhoid fever. In the reports of 195 epidemics 
collected, typhoid existed at the dairy in 148 instances; in 24 cases the 
employees acted as nurses to typhoid patients, and in 10 they continued 
at work, although themselves suffering from the disease. 

Next to typhoid the disease most often spread through milk is scar- 
let fever. The sudden and simultaneous development of a considerable 
number of cases in a community should lead one to consider the milk 
supply as a possible cause. Of 99 epidemics of scarlet fever, there was 
disease at the farm or dairy in 68; in 17, employees were themselves 
affected, and in 10 they acted as nurses. 

During 1911 and 1912 extensive epidemics of septic sore throat oc- 
curred in Boston, Chicago and Baltimore. which were traced to strepto- 
cocci spread through milk. 

Besides the diseases mentioned, diphtheria, cholera, dysentery, arid 
certain forms of diarrheal diseases may be spread by milk. 

3. Other- Bacteria Found in Milk. — These are chiefly derived from 
the dust of the stable, the hands and clothing of the milker, and from the 
dirt which falls from the udder and belly of the cow into the pail during 
milking; very many come from the cow's excreta. Freeman exposed 
a Petri gelatin-plate beneath a cow's udder for one minute during 
milking and obtained 4,450 colonies. The varieties of bacteria found 
in fresh milk are many and vary with locality. Toward the souring 
point the great majority are of two or three varieties only; fully 95 
per cent at that time belong to the lactic-acid-producing group. They 
cause the ordinary souring of milk by acting upon the milk sugar. Colon 
bacilli are very common. Other bacteria act upon the milk protein, 



COW'S MILK 147 

inducing various putrefactive changes ; and still others have a peptonizing 
power. 

Many of the bacteria are harmless. Others, while not strictly patho- 
genic, yet when present in large numbers induce changes in milk that in 
susceptible infants may cause serious illness. The relation of bacterial 
contamination of milk to infantile diarrheas is considered in the intro- 
ductory chapter upon Diarrheal Diseases. 

The Number of Bacteria in Milk. — This depends upon three condi- 
tions: (1) Cleanliness in handling; (2) temperature; (3) age of the 
milk. Hence the bacterial count becomes of value in furnishing in- 
formation as to these matters, although of less importance in regard 
to the production of disease than the nature of the organisms present. 
The influence of temperature alone upon the multiplication of bacteria 
in milk is well shown by the following experiment: Four samples of 
the same milk were kept at different temperatures for twenty-four hours 
and equal quantities were then plated; No. I was kept at 60° F. and 
showed 134,340 colonies; No. II was kept at 55° F. and showed 67,170; 
No. Ill was kept at 50° F. and showed 1,362; No. IV was kept at 45° 
F. and showed 448. 

The number of bacteria in bottled milk from good single dairies 
usually ranges from 10,000 to 50,000 per c.cm., according to the season. 
Milk from mixed dairies delivered in cans usually ranges from 100,000 
to 1,000,000, though much higher figures are often reached in very 
hot weather. 

The number of bacteria in cream is nearly always greater than in 
milk. Freeman's experiments with gravity cream showed that the bac- 
teria were 300 times as numerous in the cream as in the milk left be- 
hind, the bacteria being apparently carried up with the fat globules. 
This emphasizes the necessity of the greatest care with reference to the 
use of cream. 

A Bacteriological Standard for Pure Milk. — It is impossible and un- 
desirable to fix a numerical bacteriological standard for pure milk. One 
milk commission requires that the milk shall not have more than .10,000 
bacteria in each cubic centimeter; another fixes the limit at 30,000. A 
milk commission should insist that milk be produced from healthy ani- 
mals and under the most hygienic conditions, that it be handled only by 
healthy persons, and that every possible precaution be taken to exclude 
pathogenic germs. It is possible to lay too much stress upon the mere 
number of bacteria. There is no evidence that when the conditions men- 
tioned have been fulfilled the results in infant feeding are better with 
a milk containing 5,000 bacteria or less, than with one containing 20,000. 
Nor is there any proof that milk containing 20,000 or 30,000 bacteria 
per c.cm. is for this reason alone injurious. A low bacterial count may 



148 



NUTRITION 



be taken as presumptive evidence that the milk is produced under hy- 
gienic conditions and carefully handled, and in such circumstances the 
entrance of pathogenic germs is improbable. Such a milk is therefore 
preferable. While it is quite possible to produce milk which is prac- 
tically sterile, the expense entailed is so great as to make the com- 
mercial production of such milk impracticable. 

The Means of Excluding Pathogenic Bacteria, and of Checking the 
Spread of Contagious Diseases through Milk. — Eules are readily de- 
ducible from a study of the records of how milk has usually been infected. 

1. No person suffering from, or in contact with, a contagious disease 
should enter a dairy building or come in contact with the milk or milk- 
utensils. Children, domestic animals, and, so far as possible, flies should 
be excluded from rooms where milk is handled. 

2. Milk should not be handled in or near dwellings, privies, or sta- 
bles; cans and pails should be washed only at the dairy, and after ordi- 
nary cleansing they should be boiled or sterilized with live steam. 

3. Dairies should be subject to regular city or state inspection. Milk 
from cows showing physical evidence of tuberculosis should be excluded ; 
also that from animals which are in any way sick or are suffering from 
disease of the udder. Milk from apparently healthy animals which re- 
spond to the tuberculin test should not be used for food in a raw state. 

4. During epidemics of scarlet or typhoid fever or septic sore throat 
no raw milk should be used; and all cases of such diseases occurring in 
the families of those who produce or handle the milk should be imme- 
diately reported and isolated by the authorities. Most of the rules men- 
tioned are enforced by milk commissions which supervise the production 
of "certified milk." 

Composition of Cow's Milk. — Except in the percentage of fat, the 
composition of mixed or herd milk does not vary greatly with the dif- 
ferent breeds. The fat is lowest in the Holsteins, and highest in the 
Jerseys. 

Composition of Cow's Milk i 





Jerseys 


Holsteins 


Average Good 
Herd Milk. 


Fat 


5.61 
5.15 
3.91 
0.74 
15.41 
84.59 


3.46 

4.84 

3.39 

0.74 

12.43 

87.57 


4.00 


Sugar 


4.75 


Protein 


3.50 


Ash 


0.75 


Total Solids 


13.00 


Water 


87.00 






Total 


100.00 


100.00 


100.00 







1 In the table the figures for Jersey and Holstein herds are the averages 
given by the New York State Experiment Station. The requirements in New 
York and most of the States are, fat, at least 3 per cent; total solids, 12 per cent. 



COW'S MILK 149 

In a poor milk the only important difference to be considered is that 
the fat is from 0.5 to 1 per cent lower than the averages given. In 
Jersey milk the chief difference is that the fat is 1 to 1.5 per cent higher 
than the averages ; there is also an increase, though a less important one, 
in the other solids. As to the relative advantages of the different breeds 
for infant feeding, the difference does not seem great, provided all 
are equally healthy. Jerseys and all highly bred animals are more 
prone to disease and minor disturbances than the hardier common 
breeds. 

The Examination of Cow's Milk. — The application of heat often 
causes coagulation in milk which is near the souring point, and also in 
colostrum milk. Both are unfit for use. The normal reaction of cow's 
milk is amphoteric or slightly acid; if alkaline, it is pretty certain that 
something has been added to it. 

The specific gravity is from 1.028 to 1.033. If the cream has been 
removed, the specific gravity is raised; if water has been added, the 
specific gravity is lowered. 

The best of all ready methods of determining the fat content is the 
Babcock test. The cream-gauge may be used as for woman's milk, the 
100 c.c. size to be preferred; but it is not to be relied upon unless the 
milk is put into the cylinder soon after it is drawn and cooled rapidly 
by being placed in ice-water. Under these conditions, if the reading is 
made after eight to twelve hours, the percentage of cream to that of 
fat is about three to one. 

A microscopical examination of the cream and the sediment may 
give valuable information. Not much can be learned from a study of 
the fat globules, but among them may be found colostrum corpuscles, 
which are usually present for nearly a week after calving. The sedi- 
ment after centrifuging should be examined to ascertain the number and 
character of the cells present and should be stained for bacteria. The 
character of the cells can best be determined by the use of a differential 
blood stain. A few leucocytes are almost invariably found in normal 
milk; epithelial cells and lymphocytes may be present in quite large 
numbers without impairing the quality of the milk. However, eosino- 
phile cells and polymorphonuclear neutrophiles, when in large numbers 
or in clumps, invariably indicate disease in the cow and the milk should 
be rejected. Such milk is often ropy in consistency owing to the pres- 
ence of mucus and usually contains many long chains of streptococci. 
When used for infants it may excite severe digestive disturbances, usually 
diarrhea. Red blood cells in milk may be due to traumatism, to in- 
flammation or to the fact that milk is taken too soon after calving. 
Whenever polymorphonuclear leucocytes, blood or streptococci are at all 
numerous, the milk should not be used and a thorough inspection of 



150 



NUTRITION 



the herd should be made. The only sure way of demonstrating the 
presence of tubercle bacilli in milk is by animal inoculation. 

The casein 1 of cow's milk is readily coagulated by rennet and by 
acids. The curd formed by the gastric juice is tough and firm and is 
more slowly dissolved by the action of the digestive fluids. The casein of 
woman's milk is not regularly coagulated by rennet, and only slightly 
and with difficulty by acids. The curd formed by the gastric juice is 
loose and flocculent, and is readily and completely dissolved. 

The inorganic salts in cow's milk are about three and a half times 
as abundant as in woman's milk; but as will be seen in the following 
table, the proportion in which the principal salts are present is very 
nearly the same, the only notable exception being in the phosphoric acid. 





Cow's 2 


Woman's 3 


CaO 


22.8%' 
2.8% 
27.4% 
24.7% 
10.9% 
15.5% 


23.3% 


MgO 


3.7% 


P 2 5 


16.6% 


K 2 


28.3% 


Na 2 


7.2% 


CI 


16.5% 







The large amount in cow's milk is mainly derived from the casein. 
Even when diluted twice the chief salts of cow's milk are still in excess 
of those in woman's milk. In all dilutions of cow's milk the total salts 
may be calculated as one-fifth the protein. The ratio thus is about the 
same as salts to protein in woman's milk. The larger amount of total 
salts in cow's milk apparently has no injurious effect upon the digestion 
of healthy infants ; most of the excess is not absorbed or retained. Thus 
while an infant fed on woman's milk absorbs about 80 to 85 per cent 
of the salts in the milk and retains from 40 to 50 per cent, one fed on 
cow's milk absorbs only about 60 per cent and retains about 15 per cent. 
The ash of milk, however, does not accurately represent its mineral 
constituents. About 8 per cent of the phosphoric acid of the ash, accord- 
ing to Richmond, is derived from the casein; sulphuric acid, though 
traces are found in milk, is not to be regarded as one of its true mineral 

1 By Haliburton and some other chemists the term caseinogen is given to 
this protein as it exists in milk. When this is acted upon by rennet it splits 
up into two substances: One, the firm, insoluble coagulum to which only the 
term casein is applied; the other, a soluble protein which is known as whey- 
protein; this is present in but small amount. Those who use the term casein 
to designate the protein as it exists in milk, refer to the curd formed by the 
action of rennet in the stomach as paracasein. 

2 Average of four standard authorities. 

3 Average of sixteen analyses of mature milk, Courtney anal Fales. 



COW'S MILK 



151 



constituents. The most recent analyses show the presence of citric acid 
in both woman's and cow's milk. 

The amount of iron in milk is extremely small. In woman's milk it 
is about 1.5 mgm. per liter or .00015 per cent (Bahrdt and Edelstein). 
In cow's milk it is only about one-third this — really a negligible quantity. 

Bacteria. — Cow's milk always contains a large number of bacteria 
which increase in proportion to the age of the milk; woman's milk is 
seldom quite sterile but contains a few cocci from the milk ducts. To 
what degree the bacterial content of cow's milk affects its digestibility by 
healthy infants, it is impossible to make positive statements. There 
seems abundant clinical evidence that excessive bacterial contamination 
of the varieties commonly present in milk are detrimental even to healthy 
infants, and that to the delicate, the feeble and the diseased their effects 
are most injurious. So far as the production of disease is concerned, it is 
of course the nature, not the number of bacteria which is important. 
The beneficial effects seen of sterilizing or boiling the milk fed to feeble 
children are only in part to be ascribed to the destruction of bacteria. 

Cream. — A great misapprehension exists as to its composition. It is 
often spoken of as if it were something entirely different from milk. 
It should be regarded rather as milk which contains an excess of fat. 
Cream was formerly obtained by skimming — the gravity process; at 
present, almost entirely by the use of a centrifugal machine known as a 
separator. The latter process has the advantage in point of time, as 
centrifugal cream can be put upon the market from twenty-four to thirty- 
six hours earlier than gravity cream. 

The following table gives the composition of an average milk and of 
centrifugal cream of different densities removed from the same milk: 





Whole 
Milk. 


Cream. 




I. 


II. 


ill. 


IV. 


V. 


Fat 


4.00 
4.75 
3.50 
0.75 


8.00 
4.60 
3.40 
0.70 


12.00 
4.50 
3.30 
0.65 


16.00 
4.15 
3.20 
0.60 


20.00 
3.90 
3.05 
0.55 


40.00 


Sugar . 


3.00 


Protein 


2.20 


Salts . . 


0.45 







The percentages of protein and sugar in the 8 and 12-per-cent 
cream are but little lower than in milk; in the very rich creams they 
are reduced by about one-third. 

It is unfortunate that no general standard exists as to what shall be 
sold as cream. In Xew York State the law provides that cream shall 
contain at least 18 per cent fat. Very rich, centrifugal cream 1ms from 
35 to 40 per cent fat; the usual centrifugal cream has about 18 to 20 



152 NUTRITION 

per cent. Gravity cream has generally from 16 to 20 per cent fat. 

None of the methods for determining the fat in milk is applicable 
to cream, except the Babcock test. Snch variation exists in the strength 
of cream that the physician who is prescribing it for infants should have 
tests frequently made. 

Methods of Obtaining 1 Milk Containing' Various Proportions of Fat 
— Top-Milk, Skimmed Milk. — To secure a milk for infant feeding which 
is fresh and at the same time one which contains a larger proportion of 
fat than does whole milk, one may remove only a certain number of 
ounces from the top of a quart bottle. If cow's milk is put into bottles 
soon after it is drawn and rapidly cooled, the top-milk may be removed 
after four hours. Milk bottled at dairies and then transported should 
be allowed to stand after it is received for at least two hours before 
removing the top-milk. This may be done with a siphon, spoon, or a 
small special dipper; pouring off is not accurate. 

Skimmed milk, or milk which contains a smaller proportion of fat 
than does whole milk, may be obtained from bottled milk by removing 
a certain number of ounces from the top of the quart bottle and using 
only the remainder. 

It is unnecessary in practice to have a top-milk which contains more 
than 7 per cent fat; while it is desirable at times to obtain milk which 
is practically fat-free. It is also desirable to know the percentage of 
fat that is obtained when one uses various quantities from the top or 
bottom of a quart of milk. These values are only approximate, but if 
the top-milk is carefully removed, are sufficiently accurate for practical 
purposes. These may be obtained from average herd milk or very rich 
milk as follows: 



From one quart 4 per cent milk From 5 per cent milk 

Upper 16 oz. has 7% fat; upper 20 oz. 

« 20 « « 6% « . « 24 " 

" 24 " " 5% " ; all 

All " 4% " ; rest after removing top 2 oz. 

Rest after removing top 2 oz. has 3% " ; " " " " 3 " 

« « u u 4 " u cycy a . u a u « c « 

« u it U o « « i 07 « • « « « « C « 

Fat-free milk can be obtained only by the removal of the cream by a separator. 

In general it is wise for one who has much to do with infant feeding 
to have his patients take milk from the same supply to secure uniformity 
in his results. 

In or near large cities it is possible to obtain from milk laboratories 
cream or milk with any desired percentage of fat. 

Milk Sterilization. — The term sterilization is widely and rather 
loosely used to signify the heating of milk for the destruction of germs. 



COW'S MILK 153 

It should, however, be borne in mind that none of the methods com- 
monly employed renders milk sterile in the bacteriological sense of the 
word. What is accomplished is the destruction of such pathogenic germs 
as may be present, and from 95 to 99 per cent of the other bacteria, so 
as to retard for a considerable time the ordinary fermentative changes. 

The advantages of sterilizing milk are obvious. When we consider 
the enormous number of bacteria present in cow's milk with the usual 
methods of handling, and that they are frequently the cause of disease, 
it is not strange that after its introduction by Soxhlet in 1886 the 
practice of heating milk used for infant feeding rapidly extended over 
the world. Following him, the earlier experiments in sterilization were 
made at 212° F., usually continued for an hour and a half, and this 
temperature is still largely employed on the Continent of Europe. Even 
this does not render milk safe for very long. Spores are not destroyed, 
and at ordinary room temperatures spore-bearing bacteria may soon de- 
velop in such numbers as to make the milk dangerous. Since some of 
these bacteria act upon the milk-protein and not upon the sugar, such 
milk may not be sour, and hence its danger may not be recognized. 

There are some disadvantages in heating milk. The change in taste 
and the constipating effects of sterilized milk are very noticeable. Some 
of the lactose is converted into caramel, causing a slight change in color ; 
the lactalbumin is partially coagulated, this beginning at 160° F. (70° 
C), and the casein is rendered less coagulable by rennet; Eettger has 
shown that when milk is heated above 185° F. (85° C.) a volatile 
sulphid is liberated, conclusive evidence of some change in the protein; 
the organic phosphorus is changed into an inorganic phosphate; the 
citric acid is partially precipitated as calcium citrate, and some lime 
salts, which are usually soluble, are converted into insoluble com- 
pounds. Some changes also occur in the fat. Moreover, certain natural 
ferments in fresh milk are destroyed by heat. 

Many of these changes are doubtless without any injurious effect 
upon nutrition. There is, however, one important clinical reason for 
believing that the nutritive properties of milk may be impaired by heating 
to 212° F. — viz., the occurrence of scurvy in infants who are fed 
solely upon such milk for a long time. Of 379 cases of infantile scurvy 
brought together in the Report of the -American Pediatric Society, 
sterilized milk was the previous diet in 107. Many such cases have 
come under our own notice. Again and again cases of scurvy have been 
cured by simply changing from sterilized to raw milk. 

Heating at Lower Temperatures — Pasteurizing Milk. — To obviate 
the disadvantages above referred to, the practice has come largely into 
use in America of employing much lower temperatures for milk steri- 
lization. 



154 NUTRITION 

At present 150° to 155° F. (05° to 68° C.) are the temperatures 
generally employed. These temperatures are maintained from twentv to 
thirty minutes. This is sufficient to kill the bacilli of tuberculosis, diph- 
theria, and typhoid fever, and from 98 to 99.8 per cent of all other 
bacteria in milk. Nearly all of the objectionable changes produced in 
sterilized milk are avoided when the temperature is raised only to 150° 
F. (65° C), while it accomplishes the purpose for which milk is heated. 
The advantages of this form of heating are therefore obvious. But 
spores are not destroyed, and such milk requires special handling. It 
should be rapidly cooled, kept at a low temperature, and used within 
twenty-four hours after heating. 

Commercial Pasteurization of Milk. — This was first accomplished by 
passing milk through hot pipes in which it was exposed to a temperature 
of 140° to 160° F. for a brief period, usually less than one minute. 
This has been found practically to be insufficient to destroy the patho- 
genic organisms in milk. At present the method followed is known as 
the "holding process/ 5 By this the milk is slowly passed through a 
succession of vats being held at a temperature of about 150° F. for 
thirty or forty minutes. It is afterwards cooled, then drawn into ster- 
ilized containers, bottled and labeled "pasteurized" milk. For this 
process expensive and complicated apparatus is necessary and even when 
done on a large scale it adds to the cost of the milk. The limited control 
which it is possible for a municipality to exercise over milk producers 
and distributors, the impossibility of securing adequate inspection of 
dairy-farms and creameries, a conviction that a large part of the typhoid 
seen in cities and towns is milk-borne, and the occurrence of extensive 
epidemics of septic sore throat from milk infection, have forced upon 
many boards of health the necessity of compelling pasteurization of 
all milk used for food in an uncooked state unless the same is from 
"certified dairies''' supervised by competent milk commissions. This 
practice bids fair to become general. The objections to and disadvantages 
of pasteurized milk should also be considered, ^here is a temptation to 
an unscrupulous producer to neglect precautions necessary to keep milk 
clean, and at the same time to a dealer to deliver milk that otherwise 
would be unsalable because near the souring point. The. necessity of 
keeping pasteurized milk cold and of using it within twenty-four hours 
if possible, must be taught the public. The label "pasteurized milk" 
too often conveys a false sense of security and leads to the neglect 
of the precautions mentioned. The date of pasteurization should be 
stamped upon the label. It should be known that, unless milk is 
kept cold and used soon it may, even though pasteurized, contain an 
immense number of bacteria although it does not turn sour. Tbe 
closest kind of supervision should be exercised by authorities which 



u 
cammuBi 

Pasteurization vs. Sterilization, — From what has already been said 
it would appear that the argument is altogether in favor of pasteuriza- 
tion. The lowest temperature and the shortest time that will surely 
destroy the objectionable bacteria in milk would seem to merit general 
adoption. Pasteurization, however, requires considerable care, intelli- 
gence, and special apparatus. When all these can be secured it should 
be employed as the method of choice. 

Sterilization at 212° F. (100° C.) is much simpler; it can be done 
with j simple and inexpensive forms of apparatus or even without 

any special apparatus. Where no ice is available, it is safer in hot 
weather t;an pasteurization. Among the poor of our large cities, in 
summer, bailing is to be advised as the most satisfactory, and indeed 
the only efficient, method of sterilization. It should not be forgotten 
that the usu f suc ] 1 milk as the sole diet for a long time is attended 
with a certain amount of risk, even though a small one; and one should 
always be on \h e watch for the soreness of the legs and the spongy gums 
that indicate the beginning of scurvy. Heating to 212° F. on two suc- 
cessive jays is also to be recommended where milk must be kept for one 
'ji- cwo weeks, as upon ocean journeys. 

Methods of Heating Milk. — Milk for infant feeding should be 
sterilized at home preferably in small bottles, each one of which con- 
tains a sufficient quantity for one feeding. These bottles may be plugged 
with cotton or corks, or special stoppers may be used. Soxhlet's ap- 
paratus may be employed, or Arnold's, or any one of a half dozen others 
sold in the shops. All that is really necessary is to expose the bottles 
on all sides tc live steam in a closed vessel. It can be done effectively 
in any tin vessel which has a closely fitting cover and a perforated bot- 
tom, and which can be placed over a pot of boiling water. Steriliza- 
tion at 212° F. is usually continued for one hour. The bottles should 
then be cooled in water as quickly as possible and placed upon ice or in 
the coolest place available. 

A simple apparatus for pasteurizing milk has been devised by Free- 
man in which the temperature is raised to 150° F. (65° C.) by hot 
water. 1 An essential step in pasteurizing milk is rapid cooling. After 

1 Milk may be effectively, but not very accurately, pasteurized in the home 
without any apparatus in the following manner: Place the bottles of milk 
in a covered pot containing enough tepid water to cover the bottles to the neck. 
Allow this to stand on the top of a stove until the water begins to simmer. 
Now remove the pot from the stove to a table and let it stand for twenty 
minutes covered. Then cool the bottles of milk by placing them first in water 
at room temperature and afterwards in ice water. 



: fctl tf 

placed in water at the room temperature and afterward in ice-wate*, 
where they should remain half an hour before being placed in the cold 
room or ice chest. 

The sterilization of milk is useful, first, for the destruction of patho- 
genic germs; secondly, for the destructn 
mentation, thus enabling one to feed with safe 
it may be forty-eight hours old, no important ferme 
occurred. As a therapeutic measure ste milk is m 

forms of gastric or intestinal infection such as typhoid 
diarrhea, etc. It is a matter of clinical ation thai 

is sometimes well borne when raw milk is no ung 

infants. 

Shall All Milk Used for Infant Feeding Be Sterilize 
weather only the very cleanest milk can 
In winter, the heating of milk is not so nei 
is produced and handled as the bulk of niilk is a 
delivered in large cities until it is considerably over i 
old, and not consumed until over forty I hours old 
heating should invariably be practiced, unless it it 
duced and handled under the best conditions. In the 
milk is obtained fresh and used before it is >ur ho 

ilizing is unnecessary if the cows are 
handled. 

It is quite possible to produce milk which does not need sterilization. 
There are special dairies supplying such certified milk to many of our 
large cities, and their number may be very greatly increased if the med- 
ical profession will use its influence in this direction. Our preference 
for infant feeding is a milk so clean and fresh that it may be safely given 
even in summer without heating, but this is at present available only for 
the small minority. Healthy infants with good digestion usually do well 
upon raw milk even though the number of bacteria is quite large ; while 
delicate infants or those with digestive disturbances may be seriously 
affected by such milk. 

The feeding of boiled or sterilized milk must be considered quite 
apart from the question of microorganisms. There are unquestionably 
some very young and some delicate infants with feeble digestion who 
thrive better upon heated than raw milk even though the number of 
bacteria in the latter may be very small. Experiments in feeding raw 
and boiled milk to young animals for comparative results have not been 
numerous, nor quite conclusive. Those which have been published in 
Europe are rather in favor of boiled milk. The latest experiments of 
Daniels and Stuessy in this country, however, indicate that animals do 



COW'S MILK 157 

not thrive for a long period npon boiled milk ; although for the first two 
or three months those fed on boiled milk did distinctly better than those 
fed upon raw milk. Brennemann (Chicago) has made some experiments 
upon the human subject (a young adult) which show conclusively that 
boiling has a marked effect upon the coagulation of the casein in the 
stomach. Under certain conditions this seems to produce a distinctly 
beneficial effect upon digestion. However, this is far from proving that 
all milk used for infant feeding shall be so heated. The use of 
boiled milk for long periods is not to be recommended; although with 
young infants and for short periods it is frequently of the greatest 
service. 

Frozen Milk. — During very cold weather milk is often unavoidably 
delivered in a partially or completely frozen condition and the question 
frequently is raised whether any important change is produced by freez- 
ing which affects its digestibility by young infants. So far as is known 
the changes brought about are purely physical ones. Only the water of 
the milk freezes, the fat undergoing separation in consequence. When 
such milk is warmed again, the fat globules may coalesce to form an 
oily layer of butter fat. While older children or robust infants are sel- 
dom affected by such milk, considerable disturbance may be produced in 
delicate or susceptible infants. Occasionally vomiting is excited, but 
more often there is diarrhea which may become severe. The higher the 
fat percentage in the milk fed, the more severe are the symptoms likely 
to be. 

Peptonized Milk. — Milk is peptonized through the agency of a sub- 
stance derived from the pancreas, usually that of the pig. This is known 
in the market as "extractum pancreatis," the active ferment being the 
trypsin. As this acts only in an alkaline medium, bicarbonate of soda 
should first be added to the milk. The purpose of peptonizing is to 
secure a partial digestion of the protein of milk before feeding. 

Milk which has been peptonized ten minutes is not altered in taste; 
if, however, the process is continued for twenty minutes, a slightly bitter 
taste is noticed which increases with the duration of the process. Pep- 
tonizing may be arrested at any stage by raising the milk to the boiling 
point ; but if the milk is to be fed at once this is not necessary. 

Peptonized milk is useful only when the stomach is so sensitive as 
to be affected by the coagulation of milk, something which is rarely seen. 
The prolonged use of peptonized milk as the sole food is sometimes fol- 
lowed by scurvy. 

Condensed Milk. — This is prepared by heating fresh cow's milk to 
212° F. for twenty minutes for sterilization, and then evaporating in 
vacuo, so that one part of condensed milk represents about two and a 
half parts of the original milk. Sweetened condensed milk is preserved 



I 



158 



NUTRITION 



in tin cans, with the addition of about seven ounces of cane sugar to a 
pint. 

The composition of sweetened condensed milk is shown in the follow- 
ing table ; also the results obtained when it is diluted : 





Condensed 
Milk.i 


With 6 Parts 
of Water 
Added. 


With 12 
Parts of 
Water. 


With 18 
Parts of 
Water. 


Fat 


Per cent. 

9.61 
8.01 

54.94 

1.78 
25.66 


Per cent. 

1.37 
1.14 

7.89 

0.25 

89.35 


Per cent. 

0.73 
0.61 

4.75 

0.13 

94.28 


Per cent. 

0.50 


Protein 

n limr /Cane, 42.91) 

Sugar j Milk > 12 03 | 

Salts 

Water 


0.42 

2.90 

0.09 
96.09 



Analysis of Borden's Eagle-Brand condensed milk. 



The reasons both for the success and for the failure of sweetened 
condensed milk as an infant-food are apparent from a study of its com- 
position. As a temporary food it is often useful, first because it is nearly 
sterile, but chiefly because the fat of cow's milk has been reduced by the 
usual dilution to a point at which an infant with a very weak digestion 
can bear it, while it furnishes an abundance of sugar; but it is low 
in protein. Infants fed upon condensed milk are often fat, but have, as 
a rule, feeble resistance when attacked by acute disease, especially" of the 
intestinal tract. It is rare to see a child reared on condensed milk who 
does not show some evidence of rickets. The prolonged use of con- 
densed milk is sometimes a cause of scurvy. Condensed milk is admis- 
sible for temporary use during attacks of indigestion, for infants with 
feeble digestion, especially in summer, for very young infants during 
the first two or three months, or among the very poor, when the cow's 
milk which is available is still more objectionable. It should not be 
used as a permanent food when good, fresh cow's milk can be obtained. 
In travelling it is often the most convenient as well as the 
food to use. It should usually be diluted ten to twelve times I 
infant under one month, and from six to ten times for those wh 
older. 

During recent years condensed milk without any addition of sugar is 
sold in the market; in many large cities this is delivered fresh da 
bulk; it is also sold in tin cans in a sterilized form. To distingu 
from other condensed milk i( is called "evaporated milk." Its str 
is about the same as that of the better known condensed milk, i. e. 
part representing about two and a half parts of the original milk, v 
out any addition of sugar or other preservative. Evaporated milk re- 



COW'S MILK 159 

quires the same modification as ordinary cow's milk. For routine use it 
should be diluted with from eight to twelve parts of water, and sugar 
added. When diluted with water the proportion of fat and protein will 
be approximately the, same as in condensed milk given in the foregoing 
table. Additional carbohydrates may be introduced in whatever form 
may seem desirable, either as sugar (milk sugar, cane sugar, or maltose) 
or as starch (barley, oat or wheat flour). It is a sterile, cooked milk. 
Some children thrive upon it who cannot so well digest either raw milk 
of the same percentage composition or even freshly pasteurized milk. It 
should not be long continued as the sole food when good fresh milk can 
be obtained. 

Dried Milk. — Dried milk sold under various names has more recently 
been put upon the market. It is prepared either from whole milk or 
from skimmed milk. The process of manufacture most extensively em- 
ployed is that of spraying the milk upon hot revolving cylinders by which 
means the water is driven off almost instantaneously. A preparation of 
dried milk made from partially skimmed milk to which milk sugar has 
been added is sold under the name of "mammala." It contains 12 per 
cent of fat; 54 per cent of sugar; 24 per cent of protein, and 5 per cent 
of salts. A somewhat similar preparation but higher in fat is sold in 
England under the name of "glaxo." Dried milk is a sterile, white 
powder and in sealed cans keeps indefinitely. When eight parts by vol- 
ume of water are added (one level teaspoonful to the ounce) it approx- 
imates in composition the original milk. It may be further modified if 
desired. Its application is similar to that of condensed milk over which 
it presents some obvious advantages in travelling; it is open to the same 
objections as a permanent food, and should not be advised when fresh 
milk can be obtained. 

Buttermilk and Other Forms of Fermented Milk. — A^arious forms of 
fermented milk arc in use which differ according to the milk used and 
the process followed. They resemble each other in that the fermentation 
is excited by some of the varieties of lactic acid organisms, in some cases 
with the addition of yeast, which ferment a portion of the milk sugar. 
The ordinary buttermilk of commerce is sometimes made from sweet, but 
usually from sour cream. If from the hitler, it resembles the fermented 
milks in thai il contains little or no fat but a certain amount of lactic 
acid, the result of fermentation. It differs from them in that the fer- 
mentation in buttermilk is due to a great variety of lactic acid organ- 
isms; besides, it contains many other forms of bacteria than those con- 
cerned in the process of fermentation. Buttermilk should be made with 
care or it may be grossly contaminated. It, therefore, varies greatly in 
taste and considerahlv in composition under different conditions. The 
following is an average of many analyses. 



160 NUTRITION 

Buttermilk 

Fat . 50 per cent 

Milk sugar 4.00 " " 

Lactic acid 0. 80 " " 

Protein - 3.60 " " 

Inorganic salts . 75 " " 

Water 90.35 " * 

100.00 

When used as an infant food it is sometimes sterilized and sometimes 
not. The sugar content is raised by the addition of milk sugar or cane 
sugar; sometimes also barley flour or other farinaceous food is added 
A formula much used is : buttermilk, one quart ; barley flour, two even 
tablespoonf uls ; water, four ounces; cook slowly, constantly stirring, for 
twenty minutes; then add two teaspoonfuls of cane sugar. The advan- 
tages of buttermilk as an infant food are chiefly due to its low fat con- 
tent and to the small amount of lactic acid which it contains. Its cheap- 
ness is an important consideration and makes it available for the very 
poor. 

Other fermented milks, sometimes called buttermilk, are known also 
as lactic acid milk, lactobacilline, lactobacillary milk, lactone buttermilk, 
etc. They are sometimes made from whole milk but chiefly from skimmed 
milk. This is usually first sterilized and then the ferment added in the 
form of a tablet, mixture or culture from some previously fermented milk. 
The ferment consists of different varieties of lactic acid organisms; the 
one most frequently employed is known as the Bulgaricus. The product 
resembles ordinary buttermilk in its composition except that it usually 
has a higher acidity. It is a purer product since the fermentation takes 
place from one or two selected varieties of organisms and not from a 
great number as in ordinary buttermilk. It differs according to the 
exact varieties or combinations used, also according to the temperature 
maintained and the duration of the fermentation. A temperature of 80° 
to 85° F. is usually employed and this is continued from six to twelve 
hours according to the degree of acidity desired. The milk is then 
bottled and put on ice, where a slight change continues, although the 
milk alters but little for several days. The taste is rather pleasant unless 
the acidity is too pronounced. It should not contain alcohol or acetic 
acid. These fermented milks are sometimes used in acute disease, but 
chiefly in chronic intestinal conditions after the first year. They are not 
adapted to continuous use in infant feeding. 

Kumyss has been made by the Tartars for centuries from mare's milk. 
It is made in this country from cow's milk, sometimes skimmed, but 
usually from the whole milk. The fermentation is generally started with 
yeast and is continued in corked bottles usually for several days, with 



COW'S MTLK 161 

frequent agitation. Kumyss contains carbon dioxid, lactic acid, alcohol 
and traces of butyric and acetic acids. The acidity and the taste depend 
upon the duration of the process. 

ZooIaJc or matzoon is made from whole milk which is first sterilized 
and then has added to it a ferment which contains some form of yeast. 
It differs from kumyss chiefly in that the process is carried on in open 
vessels and the carbon dioxid allowed to escape. It is a thick smooth 
liquid and has a taste resembling that of sour cream. 

Both kumyss and zoolak are better adapted for use with older children 
than with infants ; they are chiefly valuable in cases of chronic intestinal 
indigestion. For infants they should be diluted with water and often 
given with a spoon since they are too thick to go through the ordinary- 
nipple. 

Protein Milk (Eiwews-Milch of Finkelstein). — In this milk modifica- 
tion is secured a mixture low in sugar with a moderate fat and a high 
protein. It must be carefully prepared to secure a uniform product. 
The average composition when made as directed below 1 is fat 3.0 to 3.5 
per cent; sugar 1.8 per cent; protein 3.75 per cent; salts 0.65 per cent. 
Its caloric value is about 15 to the ounce. The fat percentage varies 
considerably according to that of the fat of the milk used and the care 
exercised in its preparation. When less fat is desired partially skimmed 
milk may be substituted. The proportion of the ingredients other than 
the fat is pretty uniform. The total salts are a little lower than in 
whole milk; the proportion of insoluble salts, especially calcium, is, 
however, greater, while that of the soluble salts of sodium and potas- 
sium is somewhat less. Protein milk has a slightly sour, rather insipid 
taste, so that its administration to some infants is difficult. It is made 

1 To one quart of whole milk warmed to about 100° F. one-half ounce 
of liquid rennet or better one junket tablet dissolved in water is added, stirring 
for a moment only; after standing at room temperature for twenty or thirty 
minutes, or until it is firmly coagulated, it is poured upon two layers of gauze or 
cheesecloth and suspended for about one hour to drain off the whey. The curd is 
then washed twice with cold boiled water, after which the dry curd is rubbed 
through a very fine sieve with a vegetable masher, or some similar instrument, 
with the gradual addition of one pint of buttermilk. Enough boiled water 
is added to make one quart. When needed in quantity for hospital use, from 
five to ten quarts may readily be prepared at one time. After coagulation 
it is poured upon the cheesecloth and allowed to drain undisturbed for ten 
to fifteen minutes. The curd is then rolled from side to side by manipulating 
the cheesecloth and the whey removed in a few minutes. It should then 
be washed. Protein milk, made as above described, will contain the greater 
part of the fat, casein and insoluble salts of the original milk, also the salts, 
sugar and protein of the buttermilk, which makes up half its volume. The 
sugar, the albumin, the soluble salts and a little of the fat are removed with 
the whey and the wash. 



162 



NUTRITION 



more palatable by the addition of one grain of saccharine to the qnart. 

The advantages of protein milk depend upon : ( 1 ) its low sugar ; ( 2 ) 
its relatively high fat and insoluble salts whose soaps favor the produc- 
tion of formed stools and check intestinal fermentation; (3) the high 
protein (nearly all casein), which, having been precipitated and then 
mechanically subdivided, is well borne by the stomach; (4) probably to 
some degree the lactic acid organisms contained in the buttermilk. The 
high percentage of casein is readily held in suspension. When properly 
made protein milk is smooth and homogeneous and readily passes through 
an ordinary rubber nipple. It can be warmed to the usual temperature 
before feeding, but if heated much above this point the curd separates. 
Protein milk is to be regarded as a therapeutic agent, not as an infant 
food for prolonged -use. It has a wide field of usefulness in both acute 
and chronic disturbances of digestion with intolerance of carbohydrates, 
particularly those associated with diarrhea. 

Junket or Curds and Whey. — Junket is made as follows: To one 
pint of fresh lukewarm cow's milk are added two teaspoonfuls of essence 
of pepsin, liquid rennet, or half a junket tablet. It is stirred for a mo- 
ment and then allowed to stand at the room temperature until firmly 
coagulated. Junket is useful in the feeding of older children, but should 
not be given to infants. 

Whey. — The milk is coagulated with rennet as above, the curd is then 
broken up, and the whey strained through muslin by suspension. The 
composition of whey varies somewhat, depending upon the way in which 
it is prepared. If it is desired to have as little fat as possible, skimmed 
or fat-free milk should be used, and the whey should be strained through 
fine muslin without pressure. If it is desired to retain some of the fat, 
whole milk may be used, cheesecloth as a strainer, and more pressure. 
The protein of whey is chiefly lactalbumin. 

Whey is useful for infants with gastric symptoms when low fat is 
desired. Its high sugar and salt content usually contraindicate its use 
in cases with intestinal symptoms, especially if diarrhea is present. 

Whey 





Average 

46 Analyses 

(Koenig). 


From 
Whole Milk 
(Adriance). 


From 

Fat-free Milk 

(Adriance) . 


Protein 


0.86 
0.32 
4.79 
0.65 
93.38 


0.94 
0.96 
5.49 
0.48 
92.13 


1.17 


Fat 


0.04 


Sugar 


5.36 


Salts 


0.52 


Water 


92.91 






Total 


100.00 


100.00 


100.00 







BEEF PREPARATIONS 163 

Wine whey is made by simply adding sherry wine to whey prepared 
in the usual manner, in the proportion of one part to four of whey, pos- 
sibly better by using the wine to coagulate the milk (Still). The wine 
(cooking sherry preferred) is added to the milk in the proportion men- 
tioned and the mixture slowly brought to the boiling point. After stand- 
ing off the fire for three or four minutes it is strained through two layers 
of coarse muslin, or cheesecloth. Sherry whey is useful as an emergency 
food for short periods in acute illness for children who will take very 
little food; it is seldom given alone, but alternating with some other food. 



BEEF PREPARATIONS 

The nutrient value of these preparations is to be measured by the 
amount of albumin they contain — their stimulant properties by the pro- 
portion of extractives. 

Beef Juice. — Expressed beef juice is made as follows: A piece of 
round steak is slightly broiled, and the juice pressed out by a meat-press 
or a lemon-squeezer. Two or three ounces can ordinarily be obtained 
from one pound of steak. This is seasoned with salt and given cold or 
warm, but not heated sufficiently to coagulate the albumin in solution. 

An excellent method of making beef juice without cooking is by 
taking one pound of finely chopped lean beef and eight ounces of water 
and allowing this to stand in a covered jar upon ice from six to twelve 
hours. The meat is then squeezed by twisting in coarse muslin. It is 
seasoned with salt and given as above. 

Beef extracts are not to be considered in any sense as foods. Kem- 
merich has shown that animals receiving nothing else died of starvation, 
and sooner even than when everything was withheld. They contain no 
nitrogen in the form of protein, but only in combination with the soluble 
extractives. They are stimulants, but as such are seldom required. 

Meat. — Bare scraped beef is easily digested by most young children. 
There are many conditions in which other forms of protein are not well 
borne, where children even as young as twelve months appear to digest 
this beef -pulp without difficulty. It should be made from very rare or 
raw steak, finely scraped and well salted. A tablespoonful may be given 
at one feeding to a child of eighteen months. In nutrient properties this 
far exceeds the beef preparations in the market. The alleged danger of 
tapeworm from the use of rare scraped beef or beef juice is in this country 
so slight that it may be disregarded. 

Broths. — Animal broths may be made from mutton, veal, chicken, or 
beef. A good formula for general use is the following: One pound of 
lean meat, one pint of water; let stand for two hours, then cook over a 



164 NUTRITION 

slow fire for two hours down to half a pint. After it has cooled, skim off 
the fat and strain through a cloth. The composition of a broth so made 
is given by Cheadle as follows : 

Beef Broth 

Protein 1 .02 

Extractives 1 . 82 

Fat 0.00 

Salts 0.88 

Water 96.28 

100.00 

From their composition it will be seen that broths contain very little 
nutritive material. They are stimulating and they furnish an excellent 
means of adding inorganic salts to the diet in the latter part of the first 
year. Vegetables and barley, rice or wheat flour may be cooked with the 
broth. 

Albumin Water. — This is prepared as follows: The white of one 
fresh egg is mixed with a pint of cold water, a little salt, and a teaspoon- 
ful of brandy added. It should be given cold. The nutritive value of 
this preparation, it should be borne in mind, is very small. 



CEREALS 

Barley Water. — This may be made either from the grains or from 
the barley flour. When the grains are used, the following is the formula 
which we have been accustomed to employ : To two tablespoonfuls of 
pearl barley, add one quart of water and a pinch of salt, and boil con- 
tinuously for six hours, keeping the quantity up to a quart by the addi- 
tion of water; strain through coarse muslin. It is an advantage to soak 
the barley for a few hours before cooking. The water in which it is 
soaked is not used. When cold this preparation makes a rather thin jelly. 
Its composition by analysis is as follows: 

Barley Water 

Starch 1.63 

Fat 0.05 

Protein 0.09 

Inorganic Salts . 03 

Water 98.20 

100.00 

An almost identical product may be obtained in an easier way by 
using barley flour, one even tablespoonful to each twelve ounces of water, 



INFANT FOODS 165 

and cooking for twenty minutes. A thicker jelly when desired can be 
made by nsing twice as much of the barley. 

Rice, Wheat, or Oatmeal Water, etc. — These may be made in the 
same manner as the barley water, using the same proportions either of 
the flour or the grains. These are useful as additions to milk for healthy 
infants who have reached the age of five or six months; they may also 
be given in many cases of acute or chronic indigestion when milk must 
be omitted or given in small quantities. When there is a tendency to 
constipation oatmeal is preferred; when to looseness, barley, wheat, or 
rice water. 

INFANT FOODS 

It is not possible, nor even desirable, for a physician to know all about 
the infant foods with which the market is flooded. He should, however, 
know at least that they are not perfect substitutes for breast-milk, that 
as permanent foods they are greatly inferior to properly modified cow's 
milk, and that they are capable of doing and have done much positive 
harm. Scurvy has so frequently followed their prolonged use, when given 
without the addition of fresh milk, and sometimes even when they have 
been given with it, that there can be no escaping the conclusion that they 
were the active cause. Their general use is condemned with practical 
unanimity by authorities on infant feeding. Yet by industrious and 
skilful advertising they are forced upon public attention, and are exten- 
sively used by the laity and even by the medical profession. They are 
expensive. They add little or . nothing to our resources in infant die- 
tetics; in fact, they tend to retard rather than advance our knowledge 
of this subject. 

There are, however, a few occasions when some of these preparations 
may be useful as temporary expedients or when nothing better can be 
obtained. They should be used only with a very definite knowledge of 
exactly what they do and what they do not contain. Their name is 
legion; but those most commonly employed in this country may be 
grouped as follows: 

1. The Milk Foods. — Nestle's food is perhaps the most widely known. 
The others closely resembling it in composition are the Anglo-Swiss, the 
Franco-Swiss, the American-Swiss, and Gerber's food. These foods are 
essentially sweetened condensed milk evaporated to dryness, with the 
addition of some form of flour which has been dextrinized; they all 
contain a considerable proportion of unchanged starch. 

2. The Liebig or Malted Foods. — Mellin's food may be taken as a 
type of the class. Others which resemble it more or less closely are 
Liebig's, Horlick's malted milk, and cereal milk. Mellin's food is com- 



166 



NUTRITION 



posed principally (80 per cent) of soluble carbohydrates. They are de- 
rived from malted wheat and barley flour, and are composed chiefly of 
a mixture of dextrins, dextrose, and maltose. 

3. The Farinaceous Foods. — These are imperial granum, Eidge's 
food, Hubbell's prepared wheat, and Kobinson's patent barley. The first 
consists of wheat flour previously prepared by baking, by which a small 
proportion of the starch — from one to six per cent — has been converted 
into sugar. In chemical composition these four foods are very similar, 
consisting mainly of unchanged starch which forms from seventy-five to 
eighty per cent of their solid constituents. 

4. Miscellaneous Foods, — Under this head may be mentioned Carn- 
rick's soluble food and Eskay's food. The composition of these is given 
in the following table : 

Composition of Infant-Foods 1 



Camrick's 
food. 



Fat 

Protein 

Cane sugar 

Dextrose 

Lactose (milk sugar) 

Maltose 

Dextrins 

Total Soluble carbo- 
hydrates 

Insoluble carbohy- 
drates (Starch) . . . 

Inorganic salts 

Moisture 



Nestle's 


Mellin's 


Eskay's 


Malted 


Ridge's 


Imperial 


Food. 


Food. 


Food. 


Milk. 


Food. 


granum. 


Per cent. 


Per cent. 


Per cent. 


Per cent 


Per cent. 


Per cent. 


5.50 


0.24 


1.16 


8.78 


1.11 


1.04 


14.34 


11.50 


5.82 


16.35 


11.81 


14.00 


25.00 












6\57" 

} 27.36 


60 '.80 
19.20 


153.46 2 
14 .'35 


J49.15 3 
18.80 


0.52 
l"28 


6.42 
"i.*38 


58.93 


80.00 


67.81 


67.95 


1.80 


1.80 


15.39 




21.21 




76.21 


73.54 


2.03 


3.59 


1.30 


3.86 


0.49 


0.39 


3.81 


4.73 


2.70 


3.06 


8.58 


9.23 



Per cent. 

7.45 
10.25 



27.08 

37.37 

4.42 
3.42 



1 With the exception of Nestle's food and Carnrick's soluble food, these analyses 
were made for the authors by E. E. Smith, Ph.D., M.D., of samples purchased in the 
open market. 2 Chiefly lactose. 3 Largely maltose. 



The essential feature of all infant foods is that they are composed 
principally of carbohydrates and are lacking in fat. Some of them con- 
tain a large proportion of unchanged starch. Furthermore, their pro- 
tein, though often sufficient in amount, is chiefly vegetable, not animal 
protein. No one of them can be regarded in any sense as a proper sub- 
stitute for breast-milk. 

Some of these foods — Nestle's and other milk foods, malted milk, 
cereal milk, and Carnrick's food, and even some of the farinaceous foods 
like imperial grannm — are advertised as substitutes for breast-milk and 
recommended for use alone. Others, such as Mellin's, Liebig's, and 
Eskay's foods, are intended to be used with milk. The use of any of the 






CHOICE OF METHODS OF FEEDING 167 

commercial foods alone is admissible only for short periods during de- 
rangements of digestion, when we wish to withhold for the time all milk 
fat. Their prolonged use almost invariably produces some grave dis- 
order of nutrition, most frequently scurvy. Those foods which require 
in their preparation the addition of milk are open to less serious objec- 
tions, but are not necessary or even desirable. They should never be 
used with condensed milk. When added to fresh milk they may furnish 
the additional carbohydrates required by an infant fed upon a diluted 
cow's milk. In such a case they take the place of milk sugar or cane 
sugar in the milk modification. There is no proof to sustain the claim 
that they increase the digestibility of cow's milk. Farinaceous foods may 
be used as an addition to milk after the sixth or seventh month and 
during the second year. 



CHAPTER III 

INFANT FEEDING 
CHOICE OF METHODS OF FEEDING 

The different methods of feeding which are available are : 

1. Breast-feeding, either by the mother or by a wet-nurse. 

2. Mixed feeding, or a combination of nursing and artificial feeding. 

3. Artificial feeding exclusively. 

In deciding by which one of these methods a child shall be fed, many 
circumstances must be taken into consideration : the vigor of the child, 
the health of the mother, and especially the surroundings, since these 
determine very largely the success or failure of any method employed. 

Maternal Nursing. — This is the natural and the ideal method of 
infant feeding. Every mother should nurse her infant unless there are 
some very weighty reasons to the contrary. The physician should do all 
in his power to encourage maternal nursing and to promote its success. 
He should explain to the mother how importani breast-milk is for the 
child; that fully four-fifths of the deaths under one year are in infants 
who arc artificially fed. He should also make clear the conditions by 
which alone successful nursing can be accomplished; viz., proper diet, 
regular habits of sleep and exercise, and a simple life, in so far as possible 
free from causes of nervous excitement, fatigue, overwork, or worry. 
Social engagements should be avoided. Much can be done by patience 
and persistence even in the face of many discouraging circumstances. 
Nursing may be furthered by proper care of the nipples before 1 de- 
livery, and by attention to them during the early days of nursing to 



168 NUTRITION 

prevent fissures and mastitis, which often interrupt successful nurs- 
ing. 

As a result of extensive propaganda the number of mothers of all 
classes of society who nurse their children in the United States has 
beyond question materially increased during the last ten years. This is 
a hopeful sign. Among the poor and ignorant where artificial feeding is 
not likely to be well done, all possible efforts should be made to increase 
maternal nursing as the most effective means of reducing infant mor- 
tality. 

When Maternal Nursing Should not be Attempted. — (1) No mother 
who is the subject of tuberculosis in any form, whether latent or active, 
should nurse her infant; it can only hasten the progress of the disease 
in herself, while at the same time it exposes the infant to the danger of 
infection. (2) Nursing should seldom be allowed when serious compli- 
cations have been connected with parturition, such as severe hemorrhage, 
puerperal convulsions, nephritis, or puerperal septicemia. After severe 
hemorrhage and even after sepsis, women may recover so as to nurse 
successfully. There is great danger to the child in nursing after eclamp- 
sia; even when put to the breast two or three days after the mother's 
last attack, fatal convulsions have followed. (3) If the mother is suf- 
fering from any serious chronic disease or is very delicate, since great 
harm may be done to her without any corresponding benefit to the 
child. With reference to the last-mentioned condition, an absolute opin- 
ion can not always be given at the outset. As a rule, mothers are more 
likely to succeed in nursing first or second children than subsequent 
ones. One should not be too ready to decide that there will be no milk, 
but should persist in stimulating the breasts by suckling the child. The 
milk may be delayed until the tenth or twelfth day, and yet come in such 
abundance that nursing may be successfully carried on for many months. 
In general the capacity for lactation diminishes with each successive 
pregnancy. 

Artificial Feeding vs. Wet-Nursing. — When maternal nursing is im- 
possible or undesirable, the milk of another woman would seem to be 
the most natural and best substitute. While this is theoretically true, 
the practical obstacles are so many as to put wet-nursing out of the 
question as a general method of feeding. We have in America no peasant 
class like that of Europe to draw upon ; and in the class which furnishes 
most of our wet-nurses the capacity to nurse has steadily diminished. 
The expense of a wet-nurse — thirty to forty dollars a month in New 
York — the danger of transmitting contagious disease, and the difficulty 
of obtaining proper care for her own infant, are all very serious objec- 
tions to wet-nursing. The recent advances in artificial feeding have 
placed it now on quite a different footing from that which it formerly 



CHOICE OF METHODS OF FEEDING 169 

occupied. While it is true that good breast-milk is unquestionably the 
best food, it is equally true that properly modified cow's milk is a far 
better food than the milk of many wet-nurses who are employed. These 
facts added to the constantly increasing difficulty of obtaining good wet- 
nurses have caused wet-nurses to be pretty generally discarded, even in 
our large cities, where formerly no other substitute for maternal nursing 
was considered. 

There are, however, some conditions in which wet-nurses are neces- 
sary, even indispensable. Some infants, usually those who have been 
badly started, can not be made to thrive upon any form of artificial feed- 
ing. There are also premature infants and other very delicate ones 
whose powers of assimilation are so feeble that they are reared in 
any circumstances only with the greatest difficulty, but whose chances 
of life are much increased by a good wet-nurse. Again, in young infants 
who have been suffering for some time from chronic indigestion and 
failing nutrition, the symptoms of acute inanition sometimes develop 
with great rapidity and severity. From such a condition, apparently 
hopeless, infants may sometimes be rescued by the timely assistance of 
a good wet-nurse. 

The difficulties in the way of successful infant feeding in hospitals, 
foundling asylums and other institutions for young infants are such 
that in them partial wet-nursing should be employed whenever possible, 
at least long enough to give the infant a good start. 

Mixed Feeding 1 . — Mixed feeding, or a combination of nursing and 
artificial feeding, may be employed whenever the supply of the nurse is 
insufficient. The use of one or two feedings a day from the bottle after 
the third or fourth month may do much to relieve the mother from the 
strain of nursing entirely, without disturbing the infant's progress. Dur- 
ing the later months more feedings may be introduced for the purpose 
of gradual weaning. 

BREAST-FEEDING 

Care of the Breasts during Lactation. — For the safety of both mother 
and child it is essential that the most scrupulous attention be given to 
cleanliness. The nipples, and the breasts as well, should always be care- 
fully washed after each nursing. Usually plain water is sufficient, or a 
weak boric-acid solution may be employed. 

Nursing during the First Days of Life. — This is necessary, to accus- 
tom the child and the mother to the procedure, and to empty the breasts 
of the colostrum; it probably also promotes uterine contractions. All 
these results can be attained by putting the child to the breast on the 
first day once in six hours, on the second day once in four hours. The 



170 NUTRITION 

child gets from the breast only from four to six ounces a day during 
the first two days. Did he require more nourishment before the milk- 
flow is fully established, we may be sure that Nature would not have 
been so late with her supply. The common practice of administering 
to an infant a few hours old all sorts of decoctions, with the idea that 
because he cries he is suffering from colic, can not be too strongly con- 
demned. A certain amount of crying is desirable. In exceptional cir- 
cumstances, when an infant is unusually large and strong and cries 
excessively, it may be necessary to give food even on the first day; but 
this is not to be the rule. A little warm water should first be given ; 
from two to four teaspoonfuls at a time are sufficient. If this does not 
satisfy the child, regular feeding should be begun on the second day. 
Should the milk be delayed beyond the second day, the child should be 
put to the breast at regular intervals, but only for two or three minutes, 
and then given the bottle afterwards if still hungry. It is important not 
to cease in our efforts to induce a secretion for several days longer, and 
the best of all means is the stimulation of the child's sucking. 

Nursing Habits. — Good habits of nursing and sleep are almost as 
easily formed as bad ones, provided one begins at the outset. Much of 
the wear and tear incident to the nursing period may be avoided if the 
child is trained to regular habits. Attention to these minor points often 
makes all the difference between successful and unsuccessful nursing. 
After the third day, seven nursings in the twenty-four hours are suffi- 
cient, and no more should be allowed. An infant at this age can usually 
be depended upon to take at least one long sleep of from four to six hours 
in the twenty-four. For the rest of the day the child should be awakened, 
if necessary, at the regular nursing time, and put to the breast; this plan 
being continued until ten o'clock at night. He should then be allowed 
to sleep as long as he will, and but one nursing given between this hour 
and six in the morning. In the course of two or three weeks a healthy 
infant can usually be trained to nurse and sleep with almost perfect 
regularity — frequently, when a month old, going six hours regularly at 
night without feeding. A trained nurse of our acquaintance states that 
out of thirty-three infants of which she had the care from birth, thirty- 
one were trained without difficulty in the manner stated. So far as the 
child is concerned, regular habits of feeding and sleep, and regular 
evacuations from the bowels, which nearly always go with them, are most 
important factors in infant hygiene. 

Less frequent nursing and relieving the mother of night nursing after 
the child is three months old are of the greatest value, and by lessening 
the wear and tear of nursing will often enable her to continue lactation, 
when otherwise it would be brought to an abrupt termination. On no 
account should the child be allowed to sleep upon the mother's breast, 



BREAST-FEEDING 

Schedule for Breast-Feeding 



171 



Age. 



Number of 
Nursings in 
24 Hours. 



Interval 

During 

the Day. 



Night Nursings 

Between 10 p.m. 

and 6 a.m. 



First day 

Second day 

Three days to three months 

Three to six months 

After six months 



Hours. 

6 
4 
3 
3 
4 



nor in the same bed with the mother. The temptation to frequent 
nursing is thus largely removed. No mere sentiment in regard to these 
matters should be allowed to interfere with the plain dictates of reason 
and experience. 

Symptoms of Unsuccessful Nursing during the Early Weeks. — At- 
tempts at maternal nursing so often result in failure, jeopardizing the 
health, and even endangering the life of the child, that it becomes a 
matter of the greatest importance to decide this question of nursing 
aright, and as early as possible. On the one hand, one should not hastily 
wean a child on account of symptoms which may have no connection with 
the food, nor should one advise weaning when the indigestion from which 
the infant is suffering is due to causes which are temporary and reme- 
diable. On the other hand, nursing should not be continued simply 
because a conscientious mother desires it, when every indication points 
to failure. If artificial feeding is to be employed the difficulties are 
fewer when it is begun early than after the digestive organs have been 
deranged by several weeks of poor nursing. These cases form a very 
considerable group and present peculiar difficulties in practice. While a 
decision is being reached as to the ability of the mother to nurse, there 
is required close observation and a careful study of all the conditions, 
and even then the physician is liable to make mistakes. 

The body-weight gives valuable information. The child does not gain 
or continues to lose after the usual initial loss of the first three or four 
days. Observations on the weight at least twice a week are necessary, 
and in cases presenting special difficulties the weight should be taken 
daily. 

At times there may be no vomiting, diarrhea, or even severe colic, yet 
the child may fret and worry continually, sleep but little, and show 
general discomfort. Such symptoms are sometimes due to indigestion 
but are more frequently due to hunger. In oilier cases definite symptoms 
of gastric indigestion may be present, usually vomiting or frequenl regur- 
gitation of small amounts of undigested milk, later mixed with mucus; 



172 NUTRITION 

eructations of gas with or without vomiting may occur, and distention 
of the stomach with gas and gastric colic may follow. 

More often the symptoms of indigestion are intestinal. Occasionally 
there is constipation, but as a rule the stools are frequent, thin and 
green, containing flaky masses of undigested milk, and, after a short 
time, mucus is present. At times there is much gas and the stools are 
sour and irritating. If constipation is present there is apt to be severe 
colic and sometimes abdominal distention. The almost uniform absence 
of any elevation of temperature in these cases points strongly against 
the existence of any infection, which is further indicated by the prompt 
recovery under appropriate treatment. 

Before considering the case one of inadequate nursing, or simple 
indigestion in a nursing infant, one should be careful to exclude organic 
conditions, particularly, if vomiting is present, hypertrophic stenosis of 
the pylorus. 

As the first step one should endeavor to gain some idea as to the 
quantity of milk secreted. During the first week, particularly from the 
second to the fourth day, the temperature may be elevated quite apart 
from septic or inflammatory conditions or even evidences of indigestion. 
This is particularly seen where the breasts secrete almost nothing (see 
Inanition Fever). Often when the milk is very scanty something may 
be learned from the manner in which the child takes the breast. When 
the milk is abundant, five or six minutes are often sufficient. If the milk 
is very scanty, an infant will frequently nurse half or three-quarters of 
an hour and then stop, more because he is exhausted than because he is 
satisfied. Sometimes, when the breasts are practically empty, the child 
will seize the nipple and nurse vigorously for a few moments, then drop 
it in apparent disgust and refuse to make any further efforts. The only 
satisfactory way of determining the quantity of milk secreted is to weigh 
the infant before and after nursing. This should be done at each nursing 
until all doubt is removed. If the milk is merely scanty, but not other- 
wise abnormal, the infant does not gain, but may show no symptoms of 
indigestion, such as vomiting, colic, or undigested stools, and he frets 
and cries from hunger only. 

An excessively rich milk is usually found under the following con- 
ditions : The mother is in good health, has large breasts which are full 
and tense at nursing time. In most cases she is upon a very abundant 
diet, getting little or no exercise, and frequently taking some alcoholic 
beverage with the notion that because the child is not thriving the milk 
is poor. The child may be colicky, sleepless, and uncomfortable, may 
vomit, may have frequent stools containing much undigested food, and 
may be losing in weight. A similar condition is often seen when a wet- 
nurse makes a change from the simple life and habits of her own home 



BREAST-FEEDING 173 

to the more luxurious life and diet of the family to which she goes. 
The milk then has usually a high specific gravity, is high in fat and 
usually high in protein. 

A scanty milk of a poor quality is most often seen when the mother 
is delicate or anemic, or perhaps has had a difficult or complicated 
labor, and who besides is anxious and worried. It is often with the 
greatest difficulty that one can secure the necessary half ounce required 
for examination. The milk is usually low in total solids and very low 
in fat. The specific gravity may be only 1.024 to 1.027, and the fat 
only one per cent or less. 

A disturbed or disordered milk secretion is sometimes seen when the 
milk is scanty, often when it is very abundant. Like the group of cases 
just mentioned, this is frequently met with when the mother's general 
health is below the normal, but particularly is it influenced by her 
nervous condition. It is the highly nervous, emotional, worried woman 
whose milk we are now considering. During the first week or two the 
secretion may be excessive and then rapidly diminish; or, though the 
milk continues abundant, the infant does not thrive. It is most fre- 
quently found on examination that the milk is low in fat (0.50 to 
1 per cent), while it may be high in protein (1.75 to 3.50 per cent). 
The child's symptoms are usually those of intestinal indigestion — severe 
colic, flatulence, and frequent, green, undigested stools. 

Management. — The cause of the symptoms being in the food and not 
in the child, the futility of all medicinal treatment will be at once appar- 
ent. He who expects to relieve the symptoms of indigestion by the use of 
digestive ferments, by giving something before the nursing to dilute the 
milk, or to check frequent intestinal discharges by opium or astringents, 
will be disappointed. Temporary benefit often follows a dose of castor 
oil, but unless the milk can be materially changed in composition no 
permanent improvement in the child is to be looked for. The question 
usually to be decided relates to the continuance of nursing. We have a 
choice of four courses: (1) To continue nursing, endeavoring to correct 
the milk through treatment of the mother; (2) partly to nurse and 
partly feed from the bottle; (3) to stop all nursing temporarily, pump- 
ing the breasts meanwhile to keep up the secretion while we attempt to 
improve its character; (1) to wean at once and entirely. In deciding 
which of these courses is to be adopted we must take into consideration 
the condition of the child, the severity and duration of his symptoms, 
the findings of the milk examination, and the condition of the mother. 

While the analysis of the milk is of some value in determining the 
course to be pursued, and should, if possible, be made, it is of much less 
importance than the child's symptoms. We must be guided not by what 
the milk contains, but by how seriously it disagrees. The chemical ex- 



174 NUTRITION 

animation may show the milk to be of normal average in the proportion 
of its different ingredients and yet the child be seriously upset by it; 
on the other hand, a child may be doing admirably npon a milk which 
shows proportions which differ very greatly , from the normal average. 
The question always concerns the effect of the particular milk upon the 
particular child. 

When the symptoms of indigestion are severe or have been prolonged 
it is usually a mistake to attempt to relieve the condition by simply 
substituting some other food for part of the nursings. This seldom 
leads to any material improvement in the symptoms, while it does con- 
fuse the result, since we can not now tell whether it is the breast or the 
bottle feeding which disagrees. A better plan is to stop nursing en- 
tirely for a time and try the bottle alone. If the symptoms are at once 
relieved the weaning should be permanent. 

When symptoms point to a scanty milk, but of fair quality — i. e., 
infant not gaining but without any particular symptoms of indigestion 
— one is often able to overcome the difficulties and continue the nursing 
to advantage. Until a decided increase in the milk has occurred the 
child should have supplementary feedings from the bottle in sufficient 
number to insure his being properly nourished. This may be done 
by giving one or two entire feedings a day from the bottle or a smaller 
amount may be given immediately after each nursing. In this way the 
advantage of the stimulating effect of suckling upon the secretion of 
milk is secured. 

In the treatment of the mother the first thing is to secure for her an 
undisturbed rest at night. If possible, she should be entirely relieved of 
the care of the infant at this time, and if feeding is necessary the bottle 
should be given. She should have a certain amount of fresh air every 
day, driving if possible, or walking as soon as she is able to take more 
active exercise. Gentle massage of the breasts is often useful in stimu- 
lating secretion. It should be done with care and with every precaution 
against infection, and may be repeated two or three times a day for ten 
minutes. The diet should be abundant, with a large allowance of milk 
and meat, especially beef. If there is anemia, iron should be given. 
Every means should be taken to improve her general nutrition, and 
allay her nervous symptoms for whatever benefits these improves the 
milk. If the conditions present are incident to the confinement or the 
convalescence, the prognosis is good; and in the course of a week or 
two very marked improvement may be evident, and lactation may be 
successfully continued. If, however, the conditions depend upon con- 
stitutional debility, the prognosis is much worse. Temporary im- 
provement may take place, but it soon becomes evident that the nursing 
is a failure. 



BREAST-FEEDING 175 

When the symptoms are found to be associated with an over-rich 
milk the prospects for continuing nursing are much better than when 
the milk is poor. Unless the infant's digestion is very feeble or has been 
seriously upset either with vomiting or diarrhea, one can usually so 
alter the milk by treating the mother as to make it possible to keep the 
baby at the breast. Alcohol should be prohibited; the diet, especially 
the amount of solid food, should be reduced, and the mother required to 
take daily exercise in the open air, particularly by walking. The in- 
tervals between nursings should be lengthened, always to three hours, 
and often to four. In some cases there is an advantage in diluting 
the milk by allowing the child to take water before putting him to the 
breast. The improvement following such a change in regimen is often 
immediate, and with increasing age and weight the child gradually 
becomes accustomed to and is able to digest the rich milk. If, how- 
ever, the child's symptoms of indigestion are of an aggravated type, 
whether gastric or intestinal, it will be necessary, even though the 
weight is increasing normally, to stop nursing entirely for a time. The 
breasts should be pumped at regular intervals and the child placed upon 
some other food until the symptoms are relieved, and then brought 
back gradually to breast-feeding. 

If the examination shows the milk to be of very poor quality (i. e., 
low in fat, low in total solids), whether scanty or abundant, the outlook 
is not good. It is seldom that the conditions affecting the mother, to 
which such a milk is due, can be removed. 

When we see a fretful, colicky, sleepless infant with either no gain 
in weight or a loss of a few ounces a week, and with stools which never 
approach the normal, and these conditions have lasted for three or four 
weeks, we are justified in taking the child from the breast at once. 
When the symptoms are less pronounced, and especially when, in spite 
of all discomfort and indigestion, the infant is gaining in weight, even 
though not rapidly, further efforts may be made before weaning is 
ordered. 

Summary. — Poor milk is usually low in fat and scanty in quantity, 
while the protein may be either high or low. Very rich milk is usually 
high both in fat and protein. Very poor milk can seldom be perma- 
nently improved unless the causes are very definite and of a temporary 
character. Over-rich milk can usually be improved if the true expla- 
nation for it can be reached. Results are to be judged not so much 
by the change in the composition of the milk as by improvement in the 
infant's symptoms. Since good feeding gives so much better results 
than poor nursing, if circumstances are such thai artificial feeding can 
be properly done, it is advisable to stop nursing after ;i fair trial — e. g., 
of two to three weeks — has been made, rather than waste time in pro- 



176 NUTRITION 

longed efforts to improve the breast-milk. On the other hand, under 
conditions in which feeding is likely to be very badly done, one should 
persist for a longer time in efforts to promote lactation. But in no 
circumstances should one hastily and without carefully considered reasons 
advise a woman not to try to nurse her baby. 

Wet-Nursing. — In the selection of a wet-nurse, it is by no means 
so essential as has generally been supposed, that her child shall be of 
about the same age as the child she is to nurse, for, after the first two 
or three weeks, the changes in the composition of breast-milk are in- 
significant. It is always desirable that the wet-nurse shall have nursed 
her own infant long enough to demonstrate the fact that she has an 
abundance of good milk; hence, taking a wet-nurse at the end of the 
first or second week is always fraught with considerable uncertainty. 
It is the quality of the milk, not its age, which determines whether or 
not it will agree. For an infant over one month old, a good wet-nurse 
whose milk is anywhere between one and six months old will usually 
answer perfectly well ; and even for premature infants such a milk may 
be used without hesitation, but it should at first be diluted. 

A good nurse must, first of all, be a healthy woman, free from 
syphilitic or tuberculous taint. The evidence afforded by a careful physi- 
cal examination of the nurse and her own child may be considered suf- 
ficient. The tuberculin skin test is of no value in deciding whether a 
nurse shall be accepted or rejected. We are not yet in a position to 
assert that a Wassermann test should be employed in every case before 
selecting a nurse. The nurse must have good mammary glandular 
development. The breasts should be full and hard three hours after 
nursing. They may be very large and yet supply very little milk, being 
then composed almost entirely of fat. On the other hand, some smaller 
breasts may be almost all glandular tissue and secrete an abundance 
of milk. The difference in the size of a breast before and after nursing 
is one of the best guides as to the amount of milk it is secreting. The 
nipples should be free from erosions or fissures, and long enough for 
the needs of the child. Preferably a wet-nurse should be of a phleg- 
matic temperament, and of a good moral character. This is desirable 
for personal reasons, although there is no evidence of moral qualities 
being transmitted through the milk. It is desirable that she should 
be between twenty and thirty years of age, although much more depends 
upon the individual than upon the age. An examination of the milk 
may be of some assistance in selecting a nurse; but the best evidence 
to be obtained of the character of a woman's milk is the condition of 
her own child, which should always be seen before she is accepted. It 
often happens that a woman who has had an abundant supply of milk 
for her own infant has very little for another infant for the first few 



BREAST-FEEDING 177 

days in her new surroundings. It should not be too readily decided 
that she is incompetent as a nurse, for, under most circumstances, with 
proper treatment the regular flow of milk will be re-established. 

Weaning. — Weaning should always be done gradually, when pos- 
sible, for the sake of both mother and child. Sudden weaning is apt to 
be followed by an attack of acute indigestion in the infant. This, how- 
ever, is not a necessary result, and usually depends upon the fact that 
the child is given too high percentages of cow's milk at the outset. 
Weaning in hot weather is usually to be avoided, but the harm from 
this is not nearly so great as sometimes results when lactation is unduly 
prolonged because of a prejudice against a change of food at this time. 
While there are many women of the lower classes who are able to nurse 
their children to advantage for the entire first year, the number of such 
among the upper classes is small. By the latter, nursing can rarely be 
continued beyond the ninth, and often not beyond the sixth month, 
without unduly draining the vitality of the mother and at the same time 
harming the child. Since the early months of breast feeding are the 
most important, every effort should be made to have the mother continue 
nursing for five or six months. There is seldom trouble in feeding a 
baby for the second half year who has done well upon the breast for 
the first half. 

The late months of lactation, like the early months, require close 
watching. It is a common mistake to continue both maternal and 
wet-nursing too long, oAving to a dislike of making a change when 
things are going tolerably. If it has not been done before for reasons 
previously considered, breast-feeding should be supplemented by other 
food by the ninth or tenth month in any case. The child's progress in 
weight is a good guide as to time of beginning. In the absence of 
evident signs of disease, a stationary weight for several weeks makes 
weaning advisable; a steady loss makes it imperative. 

The accompanying weight-chart (Fig. 17) illustrates this point. 

When a nursing infant has been accustomed from birth to take one 
feeding a day from the bottle — always a great convenience to a nursing 
mother — gradual weaning is generally an easy matter; otherwise it is 
sometimes an impossibility, the child refusing all food except the breast 
so long as this is given, and nothing but starvation inducing him to take 
food either from a bottle or a spoon. 

Sudden weaning may be required at any time from the development 
in the mother of acute disease of. a serious nature, such as typhoid fever 
or pneumonia, or grave chronic disease, such as tuberculosis or nephritis, 
from the intercurrence of pregnancy, or from disease of the mammary 
gland. Through many of the minor ills — mild attacks of bronchitis, 
pharyngitis, indigestion, and even malarial fever — mothers frequently 



178 



NUTRITION 



nurse their children without any seeming detriment to them or to them- 
selves. In acute illness of short duration, if severe, it is usually better, 
unless we decide to wean altogether, to feed the child from the bottle 
and to maintain the flow of milk by the occasional use of the breast-pump 
three or four times a day rather than to allow it to dry up. The previous 
flow can often be re-established after an interruption of a week or 
two, and sometimes after a much longer time. 



MONTH OF AGE. 


GMS. 


LBS. 


1 2 3 4 5 6 7 8 9 10 11 12 


9530 
9070 
8620 
8100 
7710 
7260 
6800 
6350 
5900 
5410 
4990 
4510 
4080 
3030 
3180 
2720 
2270 


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20 
19 
18 
17 
16 
15 
14 
13 
12 
11 
10 
9 
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7 
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Fig. 17. — Chart showing the Effect of Pregnancy Upon the Weight of a Nursing 
Infant. The upper line is that of the patient; the lower one is the average line 
for the first year. The infant did unusually well until the sixth month. As it did 
not seem ill, the parents were not disturbed until the loss had reached 3 lbs. Feeding 
was at once begun, and child gradually regained its lost weight. It was subsequently 
discovered that the mother was pregnant. 



In cases of sudden weaning, the food should in the beginning be very 
much weaker than for an artificially fed child of the same age. The 
change can then be made without causing disturbance. When the infant 
has become somewhat accustomed to cow's milk the strength of the food 
may be gradually increased. 

The difficulties in weaning a child who up to nine or ten months has 
had no food but the breast, are sometimes great. Much time and tact 
are necessary on the part of both physician and nurse in these cases. 
To try to teach older infants to take the bottle is unwise ; feeding from 
cup or spoon is usually quite as easy. Continued coaxing of food is 
objectionable; forcing is much worse and prolongs the struggle. In 
our experience we have found the best way to offer food at regular in- 
tervals and to take it away at once if refused. This is repeated every 
three or four hours. A variety of things may be offered — modified cow's 



ARTIFICIAL FEEDING 179 

milk, thick gruels, beef juice, broths, bread and milk, etc. The nature 
of the food seems to make very little difference. A strong-willed child 
will often hold out for twenty-four or thirty-six hours, and occasionally 
a very stubborn one is found who will do so for forty-eight hours. At 
the end of this time the pangs of hunger are generally so acute that he 
capitulates. Serious symptoms from withholding food in such circum- 
stances we have never seen. 

MIXED FEEDING 

By mixed feeding is meant a combination of nursing and artificial 
feeding. There- are no objections to this practice ; on the contrary, there 
are great advantages in giving an infant only a few breast-feedings a 
day when more are impossible. This may frequently be done in hospital 
practice, and thus a single wet-nurse may assist in the feeding of several 
infants. Mixed feeding may be resorted to whenever the milk supply 
of the mother is insufficient. If at any time the mother's health be- 
gins to suffer, she may be relieved of night nursing or of one or more 
nursings during the day, and the bottle substituted. In this way she 
may be enabled to continue lactation for some time longer than would 
otherwise be possible. Mixed feeding is often necessary during the first 
few weeks, while the mother's milk is insufficient in consequence of 
sometfiing which has retarded her convalescence. For the advantage 
of the stimulation to secretion afforded by the child's nursing, it is 
usually better, rather than alternate the breast and the bottle, to put 
the child at first to the breasts. After he has emptied them, additional 
food may be given from the bottle if the baby is still hungry. The milk 
may become abundant and of good quality as soon as the mother is well 
enough to be up and out of doors, although it was previously scanty and 
of inferior quality. Two or three feedings a day from the bottle helps 
to bridge over this period and prevent the child's nutrition from suffer- 
ing. But before allowing a mother partly to nurse and partly to feed 
her infant, one should be sure that the quality of her milk is good. 



ARTIFICIAL FEEDING 

The scientific feeding of infants, whether with woman's milk or some 
substitute, demands as a basic principle that the food furnish what the 
body needs for heat and the repair of waste or the "maintenance re- 
quirements" and also for its normal development or "growth require- 
ments." In breast feeding there is, under normal conditions, a certain 
automatic adjustment between the amount of food needed and the amount 



180 NUTRITION 

supplied. If the milk taken is greatly in excess of requirements, this 
excess is either disposed of by vomiting or passes through the bowels in 
large partly digested stools. Sometimes this results in considerable 
disturbances of digestion; but usually they are slight. If the milk se- 
creted is much below the child's requirements, this fact becomes evident 
by slower growth and by symptoms of defective nutrition, of which the 
weight is the best guide. 

In artificial feeding, simply because the food given is not a normal 
one for the individual, it becomes even more important that the require- 
ments of the infant, as nearly as they can be determined, shall be met. 
With any substitute both an excess and a deficiency are more potent 
for harm than with the natural food of the infant. The best results 
with artificial feeding, i. e., most satisfactory growth and freedom from 
disturbances of digestion, are seen when all that the body needs is sup- 
plied but no more than this. 

The appetite of the child has been deemed by many a sufficient 
guide to the amount of food needed; to give a child all he will take 
at one time and postpone the next feeding until he shows that he is 
hungry has been advocated as a "natural" method of feeding as opposed 
to the more commonly followed plan of definite quantities at regular 
intervals. Though important, the child's appetite alone can hardly be 
relied upon. There are many infants, like many adults, who will habitu- 
ally take too much food if it is offered. Disorders of digestion not in- 
frequently are accompanied by an unnatural desire for food. 

Formerly, it was customary to indicate the amount of food given 
to an infant by stating the number of ounces in twenty-four hours. 
This, however, is really meaningless unless the strength of the food 
is also mentioned. In deciding the amount of food to be given the 
nutritive or caloric value of the food must be taken into account. We 
must know approximately the infant's needs, best stated in calories, 
and then in what form these may best be furnished, best stated in the 
percentages of the different food elements. 

From numerous observations the nutritive needs of an infant of 
average size and weight and activity in health have been shown to be 
100 to 110 calories per kilo. (45 to 48 per pound) of body weight for 
the early months of the first year; gradually diminishing to 70 to 80 
per kilo. (30 to 35 per pound) by the end of the year. A food much 
above or one much below normal requirements may be equally unsuit- 
able and therefore unsuccessful. The physician should therefore be able 
to calculate the caloric value * of the food given to see, if possible, when 
an infant is not thriving, where the mistake lies. 

^he caloric value of any modification of cow's milk of known percentages 
may be calculated as follows: 



ARTIFICIAL FEEDING 



181 



For the average healthy infant the weight is perhaps the most im- 
portant single factor, but age, size, appetite and general behavior must 
also be taken into account. The experienced physician or nurse by closely 
watching a child's symptoms is able to decide whether the food is ade- 
quate, excessive or deficient. Food needs based on weight are useful 
as a general guide until the individual factor can be determined. 

General Principles. — There are certain principles in infant feeding 
upon which all pediatrists are agreed: Woman's milk is not only the 
best, it is the ideal infant food; in any substitute certain conditions 
must be fulfilled. 

1. All the different food constituents — fat, carbohydrate, protein, 
salts and water, must be furnished. 

2. They must be supplied in sufficient quantity for the physiological 
requirements of the infant for growth, energy and repair. 

In this respect as in many others Nature tolerates considerable varia- 

For instance, 36 ounces of food having fat, 3.50; sugar, 7.00; protein, 1.75 
per cent. 

.035 (fat per cent) x 9 . 3 caloric value of fat = . 325 caloric value of fat in 1 gram of food 

.07 (sugar " " ) x4.1 " " " sugar =.287 " " " sugar " 1 " " " 

.0175 (protein " " ) x4.1 " " " protein =.072 " " " protein " 1 " " " 



.684 



" " one gram of food 
738, caloric value total food 



.684 x 30 = 20.5 (caloric value 1 ounce of food) x 36 

Such calculations are too laborious for practical use. Fraley (Archives of 
Pediatrics, 1912, p. 123) has deduced a simple formula which makes this an easy 
matter and gives results quite accurate. This we have slightly modified: 

Twice the fat percentage, plus sugar percentage, plus protein percentage, mul- 
tiplied by 1.3, gives the calories per ounce of food. Applying this to the formula 
above mentioned: 7 + 7 -f- 1 .75 = 15.75 X 1-3 = 20.5 calories per ounce. 

Another simple way is to multiply the caloric value of each of the ingredients 
in the food by the amount of each that is taken. 



Approximate Caloric Value of Different Foods 



Woman's milk 

Cow's milk 

Cream (20 per cent) 

Top-milk (7 per cent) , 

Skimmed milk (lj/2% fat) 

Whey, buttermilk, fat-free milk . 

Sweetened condensed milk 

Evaporated milk 

Dried milk (Mammala) 

Milk sugar 

Cane sugar 



Ounce 



20 

20 

60 

30 

14 

10 

100 

55 

127 

120 

120 



Even 
Tabl'sp'l, 



Dextrimaltose 

Malt soup extract 

Barley flour 

Wheat flour 

Oat flour 

Barley gruel (1 oz. to 10 oz.) .... 
Barley water ( 1 tablesp'f ul to 1 pt) 
Albumin water (white one egg to 

1 Pt.) 

Beef juice 

Orange juice 

Olive oil 



Ounce 



120 
80 
100 
100 
115 
10 
2 

1 

6 

15 

245 



Even 
Tabl'sp'l. 



122 



Approximate Measures 

Milk sugar 3 even tablespoonfuls = 1 ounce by weight 

Cane sugar 2 ' =1 

Dextrimaltose 3 " =1 

Barley or oat flour 3 " =1 

Wheat flour 4 " ' =1 



182 



NUTRITION 



tion from what is best without seriously hampering health or growth. 
Yet there is a maximum which if exceeded causes disturbances of diges- 
tion from overfeeding, and a minimum below which the body suffers from 
imperfect nutrition. Mistakes in the amount of food may be just as 
serious as those in its composition. 

3. The food constituents must be furnished in suitable proportions. 
The proportions best suited to the infant's needs are shown in the com- 
position of an average specimen of woman's milk. But as the normal 
variations in woman's milk may be considerable without affecting the 
infant unfavorably, so a certain amount of latitude in the composition 
of the artificial food which is substituted for woman's milk is tolerated. 
To a certain extent the different food elements, notably the fats and 
carbohydrates, are interchangeable; but this substitution must not be 
carried too far nor continued too long. In the scientific feeding of 
animals much stress is laid upon the importance of a properly "balanced 
ration" or one in which all the food elements are adequately repre- 
sented. The same necessity exists in infant feeding. Woman's milk 
is such a balanced ration and we cannot give for a long time a food in 
which the proportion of the different food elements differs widely from 
those which woman's milk contains without incurring serious risks. 

Cow's milk in some form is now almost universally accepted as the 
basis of artificial feeding. The milk of the goat or of other animals, 
though at times advantageous where good cow's milk is not available, 
has, because of many circumstances, never been general. In adapting 
cow's milk for infant feeding we must realize at the outset that no 
matter how it may be altered it is not a perfect substitute for woman's 
milk. There is no perfect substitute. But while its disadvantages may 
not be altogether removed, they may be lessened by certain changes, 
technically known as the "modification" of cow's milk. 

Differences between Cow's Milk and Woman's Milk. — There are cer- 
tain differences between cow's milk and woman's milk upon which these 
modifications are based. These relate both to the amount of the several 
constituents and their digestibility. The following table gives the pro- 
portions of the various elements which make up the two milks: 





Woman's Milk 
Average. 


Cow's Milk 
Average. 


Fat 


Per cent 

3.50 
7.50 
1.25 
0.20 

87.55 


Per cent 

4.00 


Sugar 


4.75 


Protein . . 


3.50 


Salts . 


0.75 


Water 


87.00 








100.00 


100.00 



ARTIFICIAL FEEDING 183 

These quantitative differences are important. It will be seen that 
cow's milk has a great excess of protein and salts and is deficient in 
sugar, while the proportion of fat in the two milks is nearly the same. 
When we come to use cow's milk in infant feeding, certain qualitative 
differences are discovered which from a practical point of view are of 
even more importance. The proper modification of cow's milk must 
take account of all these. During the past twenty-five years widely 
different opinions have been held as to the character of these differences 
between the two milks and consequently as to the nature of the difficul- 
ties which the infant has in digesting cow's milk. At different times 
the fat, the protein, the sugar and the salts have all been accused of 
being the chief cause of disturbances of digestion, and it is no doubt true 
that under certain circumstances any one of them may be a source of 
trouble. 

Protein. — Cow's milk contains nearly three times as much total 
protein as does woman's milk: the greater part, about five-sixths, being 
casein, and one-sixth, albumin. In the protein of woman's milk the 
proportion of casein is about one-third; of lactalbumin, two-thirds. 
The casein of cow's milk differs in many respects from the casein of 
woman's milk. The excess of protein, especially the excess of casein, 
and the differences in the two caseins was long believed to be the chief 
cause of difficulty in digesting cow's milk. The studies of the past few 
years have, however, shown that the casein of cow's milk is remarkably 
well digested and absorbed under nearly all conditions. Like that of 
woman's milk it is converted into peptones and finally broken up into 
amino acids. Metabolism experiments, moreover, have shown that nitro- 
gen retention in infants taking cow's milk is quite normal and examina- 
tion of stools rarely shows evidences of undigested protein. 

The chief difficulty in digesting casein of cow's milk seems to be 
mechanical, owing to its coagulation in the stomach of certain infants 
in large solid masses which offer some resistance to the action of the 
digestive fluids. Coagulation in large masses may be prevented in several 
ways: (1) by greater dilution of the milk; (2) by the use of gruels 
in the place of water as a diluent; (3) by boiling. Coagulation of milk 
in the stomach may be almost entirely prevented by the addition to the 
food of certain substances such as sodium citrate. It seems very doubtful 
if this is wholly desirable. 

The amount of protein of cow's milk required for infant nutrition 
is greater than that of woman's milk. The reason apparently being 
that the casein of cow's milk, which is five-sixths of the protein, is defi- 
cient in certain amino acids essential for growth. These are supplied 
abundantly in woman's milk, whose protein is two-thirds lactalbumin. 
The defects of the casein of cow's milk are in a measure overcome by 



184 NUTRITION 

increasing the quantity given. There is no evidence that the protein 
of cow's milk is harmful to the infant even when given in considerable 
excess of the amount contained in woman's milk. Disturbances of 
infant digestion are very rarely due to the protein of cow's milk. 

Fat. — The high fat content of woman's milk indicates the importance 
of fat in the nutrition of the infant. The amount of fat in cow's milk 
is about the same as in a good average sample of woman's milk, i. e., 3 to 
4 per cent. But there are certain important differences in the fat in 
the two milks. Thus the fat of cow's milk contains a much greater 
proportion (nearly eight times as much) of the volatile fatty acids. The 
marked difference in digestibility of the fat in the two milks is believed 
to depend to a considerable degree upon this fact. It is possible also 
that the freshness of the fat may have an influence. Be this as it may, 
it is found practically impossible to give to most infants as much of 
the fat of cow's milk as woman's milk contains. It is not wise to in- 
crease the amount of fat until symptoms of intolerance appear, for the 
intolerance to fat is more persistent than to any other ingredient of the 
food. Such intolerance once established, it may be weeks or months 
before a reasonable quantity can again be digested and absorbed. The 
tolerance to the fat of cow's milk varies greatly in different children. 
Some can take a large quantity and some only a small quantity. The 
difficulty is greatest with infants in the first few weeks, with the feeble 
and with those who have suffered from previous nutritional disturbances. 
Fat is also badly borne when there is disturbance of gastric or intestinal 
digestion, also in all febrile conditions, no matter from what cause, 
and during periods of very hot weather. A failure to regard these contra- 
indications is a constant source of trouble in practice. The ability to 
digest fat is probably the best index of an infant's digestive capacity. 
Those who cannot take the usual amount certainly do not thrive as 
well as those who can. Hence it follows that no part of the milk modi- 
fication needs to be more carefully watched than the amount of fat 
given. The percentage of fat that can safely be allowed to a healthy 
infant varies from 1 to 1 per cent. The latter figure should not be 
exceeded with any infant and with very many even this cannot be 
reached until the end of the first year. 

Carbohydrates. — That all the carbohydrates of woman's milk are in 
the soluble form is a strong indication that soluble carbohydrates, or 
sugars, should be the form supplied in artificial feeding. The high 
proportion in which sugar exists in woman's milk — being considerably 
greater than all the other solid constituents combined — shows how im- 
portant a part sugar serves in infant nutrition. In case sugar is not 
furnished in the food in sufficient amount, there must be more fat and 
protein supplied. 



ARTIFICIAL FEEDING 185 

The sugar in cow's milk is identical with that in woman's milk, in 
both cases being lactose in solution. In artificial feeding we have a 
choice between milk sugar, cane sugar, and maltose. 1 All of these sugars 
are about equally well borne in health ; they all, alike, have the capacity 
of increasing weight and fur] ' 1 ' heat Yef ther e are some differences 
in their effects which male t times to choose one rather 

than another. Milk sugar, being identical with the sugar in woman's 
milk, on theoretical grounds would seem preferable. It does not fer- 
ment with yeast. It is not so readily broken down in the stomach 
and hence with infants who have a disposition to vomit it is usually to 
be preferred to maltose or cane sugar. It is slightly laxative. It is 
usually well borne in health in proportions up to 6 or 7 per cent of the 
food. In all intestinal disturbances, particularly where there is a ten- 
dency to looseness of the bowels, lactose is badly borne. 

Cane sugar has the great advantage of cheapness. In a very large 
proportion of cases it apparently does quite as well as lactose or maltose. 
It is distinctly less laxative but rather more likely to ferment in the 
stomach and cause or aggravate vomiting when given in the quantities 
mentioned for lactose. 

Maltose, in the preparations in which it is used, has some peculiar 
advantages; first, its laxative effect which is rather greater than that 
of the other sugars ; secondly, in inducing a more rapid gain in weight ; 
and, finally, in a certain corrective action upon some digestive dis- 
turbances, especially when given with considerable amounts of starchy 
food. Maltose preparations have the disadvantage in breaking down 
more readily both in the stomach and in the intestine, often provoking 
and, in susceptible infants, always aggravating both vomiting and 
diarrhea. 

For routine use lactose is to be preferred except where cost is a con- 
sideration; the other sugars are to be used with the special indica- 
tions mentioned. There is often an advantage in using the different 

1 Pure maltose is expensive and practically not available for infant feeding. 
The maltose preparations used for infant feeding are mixtures of maltose and 
dextrins. In speaking of the use of maltose hereafter these preparations will be 
meant. Many such preparations are on the market. Loeflund's "malt soup 
extract" is reliable but expensive. Reliable and more moderate in price are the 
"neutral maltose" of the Maltzyme Co., the malt soup of the Maltine Co. and 
the "malt syrup" of the Freihofer Co.. Philadelphia. These preparations are 
somewhat acid. To the first five grains and to the last ten grains of potassium 
carbonate should be added for each ounce of the malt used in the food. All of 
these liquid preparations contain from 65 to 85 per cent of carbohydrates, of 
which about two-thirds is maltose and the balance chiefly dextrins. Besides 
these liquid preparations, Borcherdt's "malt soup extract" and Mead's "dextri- 
maltose" in powder should be mentioned as convenient and reliable forms of 
maltose. None of the above preparations has any appreciable diustatic action. 



186 NUTRITION 

sugars together since the amount that is well tolerated of the combined 
sugars is often greater than if the entire amount were one form of 
sugar. 

Starches. — Even very young infants are able to digest starch, though 
their capacity during the early months is limited. After the fourth 
month it notably increases and after six or seven months most healthy 
infants can readily digest as much as one ounce of starch daily, and 
some can do much more than this. This fact makes it possible to 
use starch in the form of cereal gruels under a variety of conditions 
when they may be thought desirable. With very young infants their use 
is mainly as diluents for milk when the coagulation of the casein in the 
stomach in large masses is an obstacle to digestion. With older infants 
starches may supply a considerable part of the carbohydrates when 
there is marked intolerance of all sugars. For the very slow change of 
the starch into sugar in the intestines is much less likely to cause symp- 
toms than when sugar itself in considerable amount is thrown at once 
into the intestine. Again, starches 'are useful to increase the total car- 
bohydrates when all the sugar is being given that the patient can readily 
tolerate and especially when, on account of intolerance of fats, it is de- 
sirable to raise the total carbohydrates to a point considerably higher 
than is usually given. 

Salts. — It has been customary in the past to add certain inorganic 
constituents to cow's milk used for infant feeding. Lime water has 
been most widely employed. As has already been stated in the previous 
chapter, not only calcium but practically all the salts of woman's milk 
are present in greater abundance in cow's milk, even when the latter has 
been diluted to the customary degree. These substances need not be 
added to milk to supply a deficiency in inorganic constituents, for there 
is none, except in iron. Their addition to correct the ''excessive acid- 
ity" of cow's milk is unimportant, for as used they do not do this. 
In considerable amounts, lime water, sodium bicarbonate and sodium 
citrate all delay the coagulation of milk in the stomach, and in 
large amounts may entirely prevent it. Under certain conditions the 
first-mentioned effect may possibly be desirable. It is questionable 
whether the latter ever is. At the present time we are not in a position 
to assert that the addition to milk of lime water or any of the substances 
mentioned is of value as a routine practice in infant feeding. They may 
therefore be wisely omitted with all healthy children. 

Feeding of Healthy Infants during the First Year. — It is absolutely 
necessary to consider separately the changes required by healthy infants 
with normal digestion and those required by infants with feeble or dis- 
ordered digestion. From a failure to make this distinction much con- 
fusion has arisen. The digestion of all healthy infants is very much 



ARTIFICIAL FEEDING 



187 



alike and they can be fed in much the same way; while the variations 
afforded by infants with disordered digestion are very great. 

There are two general plans according to which the indications out- 
lined in the previous pages may be met. The first plan is to use whole 
milk as indicated in the table given below, the different formulas being 
derived by simple dilution and the addition of needed sugar or other 
carbohydrates. The table gives the quantities of the different ingredients, 
the approximate percentage composition and caloric value per ounce 
of the formula obtained. The age indications are not intended to be 
closely followed. Successful infant feeding cannot be done by rule of 
thumb. However, these formulas are a useful guide as a starting-point 
with an average child until his individual needs and capacity can be 
determined by observation. They indicate what such a child in health 
may be expected to take and also how rapidly and in what way the 
food may be increased. 1 

Formulas from Whole (4 per cent) Milk 
Giving Approximate Percentage Composition and Caloric Value 





I. 


II. 


III. 


IV. 


V. 


VI. 


VII. 


VIII. 


IX. 


X. 




6 
14 

'■m 


7 
13 

'2V 2 


8 
12 


9 
11 

'2y 2 


10 
10 

'2M 


11 
9 

'2V 2 


12 
7 
1 
2 


13 
5 

2 
IV2 


14 
1 
5 
1 


15 







Gruel l (ounces) 

Sugar 2 (even tabl'sp'ls) 


5 


Total 


20 


20 


20 


20 


20 


20 


20 


20 


20 


20 








1.20 
5.70 

1^00 

11.5 


1.40 
6.00 

1^20 


1.60 
6.00 

i'40 


1.80 
6.50 

1^60 


2.00 
6.50 

^75 


2.20 
6.50 

i^90 


2.40 

6.00 

.40 

2.10 


2.60 

5.50 

.80 

2.25 


2.80 
5.50 
2.00 
2.40 


3.00 




5.00 


Starch, per cent 


2.00 
2.60 






Calories per ounce 


12.5 


13.5 


14.5 


15.5 


16.5 


17.0 


18.0 


20.0 


21.0 


Approx. age indication . . 


2 da. 


1 wk. 


3 wk. 


2 mo. 


3 mo. 


4 mo. 


5 mo. 


6 mo. 


8 mo. 


9-11 
mo. 



1 The gruel here indicated is made in the proportion of 1 oz. by volume to 10 oz. of water. 

2 Milk sugar is here indicated; of cane sugar use two scant tablespoonfuls instead of two and a half, 
and one instead of one and a half, etc. Maltose may be used in the same amounts as milk sugar. 



1 A simple method of calculating a milk formula for an average healthy 
infant on the basis of caloric requirements is to start with the daily amount of 
protein of cow's milk needed. This by experience has been found to be furnished 
in li ounces of milk for each pound of body weight. An infant weighing 10 
pounds will thus require 15 ounces of milk. His caloric needs calculated at 45 
per pound will be 450. Of this there will be furnished in- the milk (20 calories 
per ounce) 300 calories, leaving 150 to be made up by more fat or by carbo- 
hydrates — sugar or starch. One ounce of sugar will add 120 calories; or 1! 
ounces, 150 calories. This will give the food values for a day. There is still to 
be determined the amount of diluent, which will depend upon tin; infant's daily 
need of fluid. This has been shown to be about 3 ounces for each pound of 
body weight in the early months, and 2 ounces for each pound in the later 



188 NUTRITION 

According to the second plan of feeding, after the first few weeks 
somewhat higher fat is employed than indicated above. This is accom- 
plished by using the upper half of a quart bottle of milk, i. e., a 7 per cent 
top-milk x instead of whole milk. If this is done the amount of the 
milk used should be one-fourth or one-third less than is given in the 
table. These formulas may be used up to seven or eight months, when, 
with the introduction of larger amounts of starchy food, formulas from 
whole milk may be given. Such formulas are designed for infants who 
are able to take more fat than is contained in the formulas from whole 
milk. In this group will be found strong children with good digestion. 

Relative Advantages of Formulas from Whole Milk and Those with 
Higher Fats. — Whole milk formulas are somewhat simpler to prepare 
and the method is therefore more easily understood by the average 
mother or nurse. With the ignorant or careless there is less chance of 
going wrong, for it eliminates one error, by no means an uncommon 
one, of using too high fats. There is quite a large group of infants 
who are unable to digest higher proportions of fat than are given in 
this series of formulas and who are seriously disturbed if they are given : 
but there is a third group, also a large one, who can easily take higher 
fats and some thrive much better when they are given. Constipation 
also is somewhat less frequently seen when top-milk mixtures are used. 
There are then advantages in having formulas with higher fats for 
use under proper conditions. If no more fat is used than is obtained by 
using a 7 per cent top-milk, as here advised, disturbances from fat 
will very seldom be seen in healthy children. When less fat is given 
the caloric value of the food must be made up by increasing the carbo- 
hydrates and the protein. Only to a limited degree is such a substitu- 
tion possible. When fats are replaced by carbohydrates chiefly, quite 
serious disturbances of digestion may be produced. The great argument 
for the need of more fat than is obtained .with dilutions of whole milk 
is the proportion present in woman's milk. On the whole, while one 

months; i.e., for a 10-pound infant it will be 30 ounces a day. There will need 
to be added, therefore, 15 ounces of water. The formula will then be: 

15 ounces milk, giving 300 calories 
H " sugar " 150 
15 " water 

The 30 ounces of food could be divided into seven feedings of 41 ounces each, 
or into six feedings of 5 ounces each according to circumstances. The approxi- 
mate percentage composition of the formula, using 4-per-cent milk, would be: 
fat 2.00; sugar 6.00; protein 1.75. 

1 Before this top-milk is removed the milk should stand in the bottle at 
least four hours, and the top-milk should be carefully removed with a milk 
dipper, not poured off. 



I 



ARTIFICIAL FEEDING 



189 



may get on very well with such simple formulas as those from whole 
milk, in experienced hands excellent and sometimes better results are 
obtained with healthy children with somewhat more fat. In infants 
with feeble or disturbed digestion top-milk formulas should not be used 
at all. The most important thing in artificial feeding is to recognize 
at the earliest possible moment the indications making necessary an 
alteration in the food. 

Quantity at One Feeding and Frequency of Feedings. — The strength 
o^ t food and the daily quantity having been decided, the next ques- 
tioi is the number of feedings in which it is to be divided and the inter- 
vals at which they shall be given. Experience has shown that the average 
infant can digest his food better if the intervals are made longer than 
was formerly the practice. With longer intervals the quantity given 
at one time and the strength of the food may be correspondingly in- 
creased. There are few healthy infants who cannot readily be trained 
to the intervals given in the table below, in which the infant is placed 
upon three-hour feedings at the outset and upon four-hour feedings 
when six months old. The reduced number of feedings also materially 
lessens the labor of the mother or nurse. 

Schedule for Healthy Infants during the First Year 



Age 



Interval 


Night 


Feedings 


Between 


Feedings 


in 24 


Feedings 


After 6 p.m. 


Hours. 


Hours 






3 


2 


7 


3 


2 


7 


3 


2 


7 


3 


1 


6 


4 


1 


5 


4 


1 


5 


4 


1 


5 



Quantity 
for One 
Feeding 



Quantity 
for 24 
Hours 



2nd to 7th day 

2nd, 3rd and 4th weeks . . 
2nd and 3rd months 
4th and 5th months. . . . 
6th, 7th and 8th months 
9th and 10th months . . . 
11th and 12th months. . 



Ounces 

1 — 2 

2y 2 — m 

5 — G 

6^ — 7 l A 

7 — 8 

8 — 9 



Ounces 

7 — 14 

18 — 32 

24 — 35 

30 — 36 

32H — 37H 

35 — 40 

40 — 45 



A large and vigorous infant will require the larger quantities allowed, 
but these seldom need be exceeded; for a small infant the smaller quan- 
tities mentioned, and sometimes less, will be sufficient. 

This table really gives only the volume of food for the different ages. 
This is important as it secures to the infant a proper amount of water 
daily. The following table shows how the actual food requirements of 
an average infant may be met, using the formulas given on page 187, and 
in quantities mentioned. 

A schedule like the following indicates the needs of a healthy infant 
of average size, weight and activity. Bui no schedule can be closely fol- 
lowed with any given child. One cannot conclude because an infant is 
8 



190 



NUTRITION 



Age. 


Average 

Caloric 

Requirements. 


Furnished in 


1 month 


400 
500 
560 
640 
740 


7 feedings 4J4 oz. of No. III. 
7 " 4% " " No. IV. 

7 " 5 " " No. V. 


2 months 


3 " 


6 " 


5 " 7Y 2 " " No. VIII. 
5 " 7% " " No. IX. 


9 " 





six weeks old he is able to digest a certain amount of food and a certain 
other amount because he is six months old. To attempt to follow any 
schedule too closely is to violate the fundamental principle of intelligent 
feeding, which is to adapt the food to the child's requirements and 
powers of digestion at the time. Because these figures represent averages 
they form a useful basis for feeding healthy children. 

How and Where to Begin. — With all young infants, even those having 
presumably normal digestion, it is desirable to begin with a weaker food 
than would be indicated by their caloric requirements, and gradually 
increase both the strength and quantity according to the child's digestion. 
With small or feeble infants still weaker formulas should be used and the 
increase made more slowly. 

For a healthy child with normal digestion who has previously had no 
cow's milk one should begin with a lower formula than would usually 
be given to a healthy child of his size and age, but may increase the 
strength and quantity of the food more rapidly than with a younger 
infant. 

A stationary weight for a week or two, or even a loss of a few ounces, 
is of no importance, provided the change in diet can be effected without 
disturbing digestion ; for as soon as a child becomes accustomed to cow's 
milk the percentages can be raised and progress is assured. Nothing is 
easier than to disturb the digestion in the beginning by the use of too 
strong food. 

Indications for Increasing the Food. — While it is important to begin 
with weak food, it is a serious mistake to continue long with it. The 
powers of digestion are strengthened by gradually increasing the work 
the organs are given to do. Abrupt increases are almost certain to dis- 
turb digestion. 

How rapidly the increase is made will vary much with the individual 
infant. With a vigorous child above average weight, and with good 
digestion, the strength and the quantity may be increased more rapidly 
than with a smaller or less robust one. We cannot increase the food every 
week or every month regardless of other conditions. The progress in 
weight is important, yet one should not be guided by it alone. When it is 
made the chief concern, there is a constant temptation, if the child is not 



i 



ARTIFICIAL FEEDING 191 

gaining as rapidly as the mother thinks he should, to increase the food, re- 
gardless of conditions and often beyond his requirements, usually with 
the result of seriously disturbing the digestion. The best of all guides 
to increasing the food is the child's demonstrated capacity of digestion. 
To determine this the child's symptoms should be carefully watched. 
If he is not satisfied and is digesting well it is usually safe to increase 
the food ; but not more often than every three or four days in the early 
months, and every week in the later ones. 

In increasing the quantity, it is not wise to add more than two or 
three ounces to the food for the day, or a quarter or half an ounce to 
each feeding. During the early weeks both the quantity and the strength 
of the food should be increased every few days. It is well to alternate, 
first increasing the quantity; then after a few days, if still unsatisfied, 
increasing the strength; the next time increasing the quantity again, 
etc. In this way will be avoided the error into which mothers and 
nurses often fall who adopt a single formula and keep on simply in- 
creasing the quantity indefinitely whenever the child is unsatisfied. The 
increase in strength should not be greater than from one formula to 
the next of the series given. It is sometimes advisable to make the 
increase by steps only half as great as specified. 

A caution is necessary against changing the formula too frequently. 
It is not possible to modify the milk in such a way as to relieve every 
trivial discomfort or disturbance an infant may have. Nurses are 
usually ready to ascribe every slight symptom to the food, particularly 
if they have strong opinions of their own upon the subject of feeding 
and are not in full sympathy with the method employed. Very often 
the cause is outside the food and even of the organs of digestion. 

To Determine the Percentage Composition of any Milk Formula. — 
In order to appreciate the composition of any milk formula which a 
patient may be taking it is desirable to reduce this to its approximate 
percentages. One who forms the habit of making such calculations soon 
finds it easy, and secures a basis for comparison with the percentages 
given as proper for the average normal child. A simple method of cal- 
culation is as follows : To determine the percentage of any constituent 
in the food, multiply its percentage in the original milk, cream, or top- 
milk by the number of ounces of each in the food, and divide by the total 
number of ounces of food prepared. 1 



x k child is taking the following food:} Whole milk (4 per cent) 20 ounces, milk 
sugar 3 even tablespoonfuls, and water up to 35 ounces. 

The fat in the food will be f 2 of 4 or 2.27 per cent. 
The protein " " " " " H " 3.50 " 2.00 " " 
The sugar " " milk " " |jj " 4.75 " 2.71 " " 

Three even tablespoonfuls may be reckoned as 1 ounce of milk sugar, which 



192 NUTRITION 

Symptoms and Conditions Kequiring Special Food Variations. 
— In a new case the most important guide in the first food prescription 
is a knowledge of the condition of the digestive organs. One should 
know besides the age and weight, the nature and quantity of the food 
which has been taken, the appetite, the number and character of the 
stools, and also whether digestive symptoms are present, such as vomiting, 
flatulence, diarrhea, colic or constant discomfort. In any case the first 
prescription is somewhat in the nature of an experiment. Success will 
depend on how intelligently the symptoms have been judged. 

Even with infants who are properly fed there are few whose digestion 
remains perfectly normal throughout the entire first year. Changes in 
the food are therefore necessary from time to time to meet special 
symptoms which may arise. Many of these are due to disturbances of 
a minor character, but if they are recognized early and proper changes 
promptly made, more serious and protracted derangements of digestion 
can usually be avoided. This is not always an easy matter, but there 
are some indications which are very clear and definite. 

Hot Weather. — The depressing effects of very hot weather upon 
yomng infants should be appreciated. At such times less food can be 
digested and less is required. Owing to an increase in perspiration, the 
amount of water, consequently the volume of the food, should seldom 
be reduced. The indications are best met by reducing the milk, the 
sugar and the starch in the formula and making up the deficiency by 
adding water, i. e., simply by diluting the food. Especially should the 
fat of the milk be reduced. An immediate change therefore should be 
made from any top-milk formula to one from whole milk or at times 
even to one from skimmed milk. Water should also be given freely be- 
tween the feedings. But as some infants will not take it, the only alter- 
native is to give an extra amount, half an ounce to two ounces, in each 
of the feedings. As soon as the period of excessive heat has passed, the 
infant can gradually be brought back to the usual food. 

Minor Illnesses. — In attacks of acute rhinitis, otitis, tonsillitis, bron- 
chitis, etc., even though not especially severe, the food should be reduced. 
The reduction should depend upon the severity of the attack and the 
amount of fever. The child's apparent appetite is often only a demand 
for water. At least as much is needed as in normal conditions and usu- 
ally more should be offered. The indications may be met in the same 
way as outlined in the preceding paragraph. 

Vomiting. — The common causes of habitual vomiting referable to the 



in a 35-ounce mixture adds about 3 per cent of sugar. The total sugar in the 
food therefore is 2.71 + 3 = 5.71 per cent. 

The percentage composition of the food is: fat, 2.27; sugar, 5.71; protein, 2.00. 



ARTIFICIAL FEEDING 193 

food are : too frequent feedings and too much food at one time ; too much 
fat or too much sugar, especially if the sugar is either maltose or cane 
sugar. An infant who vomits often should not usually be fed at shorter 
intervals than four hours, even if only a few weeks old. Tf consider- 
able quantities are ejected almost immediately after feeding, it is gen- 
erally because too much food has been given. A diminution in the 
amount of food should bring about immediate improvement. When the 
sugar is in excess, or the fat, or both, there is vomiting or regurgitation 
of curdled milk or of a sour, watery fluid, which occurs frequently and 
often long after the feeding. The sugar should be greatly reduced or 
for a time entirely removed; cream mixtures or top-milk mixtures 
should not be used. If this is not sufficient, the fat should be still fur- 
ther reduced by using less milk or by partially skimming the milk. A 
return to the former diet should be gradual and for some time neither 
maltose nor cane sugar should be given. 

Other causes must be considered also. The child may be moved about 
too much or sometimes the clothing may be too tight. More often 
this frequent regurgitation of food soon after feeding is in consequence 
of swallowed air which the child has taken with his bottle. This is 
more likely to be the case when an infant is fed while lying upon the back 
and when taking his food very slowly owing to a very small hole in the 
nipple. He is unable to expel the gas in that position, but if lifted 
to the erect position or placed over the shoulder once or twice during 
the feeding or after it, he will often bring up a large amount of gas, 
after which the vomiting ceases. 

Constipation. — The principal causes of constipation referable to the 
food are, too small an amount of carbohydrates, and too small an amount 
of total solids, occasionally too low a proportion of fat. Habit and gen- 
eral training are also important factors. Sterilization, and to a slight 
degree pasteurization, cause milk to be somewhat constipating. During 
the first few weeks, if the food is rather small in amount, there is often 
a species of constipation present which is simply the result of the low 
total solids in the food given. The bowels may move every day, some- 
times even twice a day, but the stools are often small and rather dry. 
Unless there is manifest discomfort on the part of the infant, such a 
condition may be disregarded, especially if the odor and color of the 
stools are nearly normal. As the proportions of all the elements of 
the food are gradually increased this form of constipation passes away. 
Mothers and physicians often expect that the bottle-fed infant will have 
during his first one or two months the two or three large stools daily 
to which they have been accustomed with healthy breast-fed infants; 
but finding instead only one movement a day, and that small and some- 
times dry, they resort to laxatives or enemata, and by llieir use really 



194 NUTRITION 

cause much of the trouble they are seeking to remove. If milk mixtures 
are made up without the addition of carbohydrates, constipation fre- 
quently results. This is often due to the alteration in the reaction of the 
contents of the intestines brought about by putrefaction of the protein. 

Milk sugar is somewhat laxative and if a smaller amount is being 
used the raising of the proportion of this ingredient as high as 7 per 
cent will often be all that is needed. Maltose is more laxative in its 
effects and may be substituted wholly or in part for milk sugar. Its 
use will be more fully discussed later. Maltose should not be given if 
there is vomiting. Cereal gruels, especially oatmeal, also have a favor- 
able influence upon constipation. 

Colic and Flatulence. — The habitual colic of early infancy may occur 
with any form of intestinal indigestion; its causes therefore are varied. 
Colic and flatulence are especially common in infants who suffer from 
constipation. Excessive flatulence may occur also when cereal gruels 
are added to the milk of young infants, particularly if the amount is 
large. If symptoms are severe a reduction in all the elements of the food 
may be necessary. 

"Curds' in the Stools. — The undigested masses appearing in the 
stools of infants taking milk are usually spoken of as "curds." These 
may be small, soft and white, and may make up a large part of the loose 
stool. An excess of mucus is usually present. Such masses are com- 
posed almost entirely of fat. There are also seen, but much less fre- 
quently, larger, smooth, hard masses of a yellowish-brown color, but 
white on section. They are generally present in small numbers in a 
stool, the rest of which may be quite normal. These hard or "bean 
curds," so called from their resemblance to lima beans, are composed 
chiefly of protein, usually with an envelope of fat. They are undoubtedly 
formed in the stomach, where the casein coagulates in masses, some of 
which are so firm and hard that they pass the intestine without being 
digested. Curds of this description are rarely seen unless the proportion 
of casein in the food is high. 

Curds of the first variety, if numerous, call for a considerable reduc- 
tion in the amount of fat. The large, smooth, hard curds, if numerous 
and persistent, may usually be made to disappear by boiling the milk. 
This causes the precipitation of the casein to occur in smaller masses 
which are more readily attacked by the gastric and intestinal secretions. 

Loose, Green, or Yellowish- green Stools of a Sour Odor. — These are 
usually due to too much sugar, especially lactose, sometimes also to an 
excess of fat. The number of stools is usually from two to Ave daily. 
In appearance the stools resemble thin scrambled eggs. Stools such 
as those described arc often seen in nursing infants as well as in those 
artificially fed, and the condition is not incompatible with steady and 



ARTIFICIAL FEEDING 195 

regular gain in weight. After it has persisted any length of time, mucus 
is regularly present. 

Large, Dry, Light-colored Stools. — Such stools are seen only if in- 
fants are fed preponderately or entirely upon cow's milk. The bowels 
are constipated and the stools may not be passed oftener than once in 
forty-eight hours. They are relatively large, however, and are so dry 
that the diaper may be hardly soiled. In addition, they are putty- 
colored or grayish-green and are very foul with the odor of putrefac- 
tion. On analysis they are found to be alkaline in reaction and to con- 
tain a large i)roportion of calcium and magnesium soaps. For a time, 
infants with such stools may improve and gain in weight. After a 
time, however, they cease gaining and eventually lose weight while 
anemia appears of increasing severity and eventually a condition of 
marasmus may develop. To this condition the name milchndhr- 
schaden has been given by Czerny, who believed that an excess of fat 
in the diet was responsible for it. It is probably due not so much to 
an excess of fat as to an insufficient amount of carbohydrates. In the 
absence of this latter, putrefaction of the protein goes on unchecked. 
This accounts for the character of the stools. It is the insufficient 
amount of carbohydrates that is chiefly responsible for the symptoms. 
Many infants may take diluted whole milk without additional carbo- 
hydrate and never show such symptoms, but some are rapidly and seri- 
ously affected by the absence of carbohydrates. 

The condition is readily amenable to treatment. The indications are 
to diminish the milk if this has been in excess, and to add sugar alone or 
sugar and some cereal. The mere addition of milk sugar or cane sugar in 
the quantities usually given may be sufficient. At times, however, even 
when given in amounts up to the point of tolerance, no improvement is 
seen. It is then advantageous to give a preparation of maltose in the 
form of one of the malt soups, with wheat or barley flour in addition. 
The improvement is seen at once. The stools become acid in reaction, 
soft and brownish; the general condition shows a distinct amelioration 
and gain in weight again occurs. 

No Gain in Weight without evident Symptoms of Indigestion. — 
This is sometimes due to too little or too weak food, the child usually 
manifesting signs of hunger. Occasionally it is due to the fact that 
the food has been too concentrated or that too much fat has been given. 
In the latter case it frequently happens that the appetite is much re- 
duced, so that the infant takes perhaps less than half his usual allow- 
ance. Too frequent feedings and the practice of constantly coaxing the 
infant to take more food often produce the same aversion to food. 
It is much better to offer food only at four-hour intervals and lake 
away the bottle as soon as the child shows that he docs not want more. 



196 NUTRITION 

Modifications in the food to meet the indications afforded by more 
serious conditions than those here described are considered in the later 
pages devoted to Difficult Cases of Feeding. 

The Apparatus Eequired for the Preparation of Milk at 
Home. — This includes a glass graduate, a glass or agate funnel, a cream 
dipper, a pitcher for mixing food, feeding-bottles, a tall cup for warming 
the food, and a small ice-box. Other articles needed are milk sugar, 
rubber nipples, absorbent cotton, bottle-brushes, borax or boric acid, 
bicarbonate of soda, and an alcohol lamp, an electric stove, or a Bunsen 
burner. The best style of bottle is that which can be most readily 
cleaned. The graduated cylindrical bottles with wide mouths are to 
be preferred. The best nipples are those of plain black rubber, which 
slip over the neck of the bottle, and are not so thick as to prevent 
their being 4 turned inside out for cleansing. Those with a long rub- 
ber tube going to the bottom of the bottle should not be used. In 
many places their use is prohibited by law. The hole in the nipple should 
be large enough for the milk to drop rapidly when the bottle is inverted, 
but not so large that it will run in a stream. New nipples should be 
boiled; but the daily boiling of nipples is unnecessary. It soon makes 
them so soft as to be useless. They should be rinsed in cold water imme- 
diately after using and washed daily in soap and water. When not in 
use, nipples should be kept covered in a solution of borax or boric acid. 
Bottles should first be rinsed with cold water, then washed with hot 
soap-suds and a bottle-brush. When not in use they should stand full of 
water. Before the milk is put into them they should again be placed in 
boiling water for ten minutes. 

Directions for Feeding. — The food should be warmed to about 
100° F., best by placing the bottle in a tall pitcher or cup filled with 
hot water, not by pouring the food from the bottle into a saucepan. 
The temperature of the food may be tested with a thermometer, or by 
pouring a few drops upon the front of the wrist; it should feel warm, 
but not hot. The nurse should never take the nipple of the bottle into 
her own mouth. A bottle should not be warmed over for a second 
feeding. A child should not be more than twenty minutes in taking 
his food, and should not sleep with the nipple of the bottle in his 
mouth. It is preferable to have a young infant held while taking his 
bottle. If this is not done, the bottle should at least be held in such 
a position that the neck of the bottle is kept full. After feeding, the 
child should be held upright over the nurse's shoulder, and patted on 
the back, to allow him to bring up the gas, usually air which he has 
swallowed. He is then placed in his crib and left alone. It is even 
more necessary than in breast-feeding that rules as to frequency and 
regularity of meals be observed. 



ARTIFICIAL FEEDING 



107 



Directions for Preparing the Food. — All the food needed for 
twenty-four hours should be prepared at one time. The first thing to be 
decided is the formula to be used ; next, the quantity of food for twenty- 
four hours, lastly the number of feedings into which it is to be divided. 

Let us suppose for example that the child to be fed is an average 
healthy infant three months old, weighing about twelve pounds. Formula 
No. V of the series given would be an appropriate one to begin with. The 
food requirements would be furnished in about 35 ounces. This amount 
should be given in six feedings. When more than 20 ounces is needed for 
a day's supply the quantity of each ingredient should be increased : for 30 
ounces one-half more of each is used ; for 35 ounces three-quarters more ; 
for 40 ounces twice as much. Thus, using No. V, the quantities would 
be as follows : 





For 20 Ounces. 


For 30 Ounces. 


For 35 Ounces. 


For 40 Ounces. 


Whole milk 

Sugar 


10 OZ. 

2,y 2 tabl'sp'ls 
10 oz. 


15 oz. 
3U tabl'sp'ls 
15 oz. 


17H oz. 
43^ tabl'sp'ls 
17^ oz. 


20 oz. 

5 tabl'sp'ls 
20 oz. 


Water 



When barley water or gruel is used it replaces part or all the water in the 
formula. 



The milk sugar should be dissolved in boiled water, which is then 
mixed with the milk in a pitcher. The food is now divided into the 
required number of feedings and the bottles stoppered with cotton. 
They are placed at once in an ice chest, or first sterilized, then cooled, 
and afterward placed upon ice. 

Milk Laboratories. — Many of our large cities have milk labora- 
tories which put up on the prescription of physicians milk for infant 
feeding containing any desired percentages of fat, sugar, protein, etc., 
raw or heated, and with the addition of any cereals when these are 
wanted. In his prescription the physician indicates simply the percen- 
tages he wishes, together with the number of feedings and the quantity 
for each feeding. The milk is delivered daily in the bottles from which 
it is to be fed, requiring only to be warmed. The milk laboratory is 
of much assistance in infant feeding, particularly when there is no one 
in the home who has the time, the facilities or the intelligence to pre- 
pare the food properly there. To one with experience in ordering 
milk by prescription the milk laboratory is a great practical aid. The 
laboratories are particularly useful in preparing milk for long journeys 
or ocean travel. 

The Observation of Casks of Infant-Feeding. — Attention to <lc- 



198 NUTRITION 

tail is most essential. Much of the want of success in infant feeding is 
due to a failure of the physician to keep in close touch with the case. For 
the first few weeks he should see the infant every few days, inspect the 
stools, hear the nurse's report, and see how directions are being carried 
out. When the child is well started and has begun to gain regularly in 
weight, a weekly visit may be sufficient. Still later, monthly visits but 
with regular weekly reports in writing should be continued until the 
child is a year old and is taking whole milk and solid food. The weekly 
report should include answers to certain questions, viz. : 

1. Weight : gain or loss since last report. 

2. Stools : frequency and general character. 

3. Vomiting or regurgitation : when and how much ? 

4. Flatulence or colic? 

5. Appetite : Is the child satisfied ? Does he leave any of his food ? 

6. Is he comfortable and good-natured and sleeping well? 

7. The formula of the food now given: quantity and frequency of 

feedings. 

An excellent plan is to furnish the mother with a printed form con- 
taining the questions to be filled out and returned. With information 
regarding the points indicated, it is possible for the physician to know 
pretty accurately how the child is doing, what changes, if any, are desir- 
able in the food, and whether he ought to see the patient. 

It is essential to success with any method of feeding, first, that one 
should have good raw materials — the freshest and cleanest milk obtain- 
able; second, that at least the fat content of the milk or cream used 
be definitely known; third, that directions for the mother or nurse be 
clear, explicit and in writing; fourth, that one have the cooperation of 
an intelligent mother or nurse; finally, it should be remembered that 
practical success in infant feeding depends upon how intelligently a 
method is used, rather than upon the method itself, and that the one 
indispensable thing is systematic observation. 

The Use of other Food than Milk during the First Year. — Reference 
has already been made to the addition of farinaceous food in the form 
of barley water and other cereal gruels in the modification of cow's milk. 
These are useful in the first place for their mechanical effect upon casein 
coagulation in the stomach. For this purpose only a small amount of 
the cereal making a weak gruel is necessary, e. g., one or two teaspoonfuls 
of the flour to the daily food. Farinaceous food may also be given 
when, because low fats are used from choice or necessity, the carbohy- 
drates should be increased. Instead of doing tin's entirely by some form 
of sugar, part of the carbohydrates may in many cases advantageously be 
furnished in the form of starch. This may be given as a gruel made from 
wheat, oat, or barley flour, or arrowroot. The amount of the flour used 



ARTIFICIAL FEEDING 199 

in the daily food should seldom be over one-fourth ounce under three 
months of age; from three to six months, from one-half to one and one- 
half ounces may be given; from six to ten months, from one and one- 
half to two ounces; all the above being by volume, not weight. The flour 
should be cooked for ten to twenty minutes in the water used for diluting 
the milk. If grains instead of flour are used the cooking should be for 
at least three hours and the gruel should be carefully strained before 
using. After ten or eleven months cereal may be given with a spoon. 
This may be almost any form of well-cooked cereal which has been 
strained. It may be cooked with milk or the milk may be added subse- 
quently. Beginning with an ounce a day the quantity may be gradually 
increased to two ounces twice a day. While many children easily digest 
the amounts of starch mentioned, there are others who are much dis- 
turbed by them, and some to whom, owing to flatulence and other symp- 
toms of intestinal indigestion, starch can not be given at all. 

The only other things to be advised during the first year are beef 
juice and the juice of some fresh fruit. Beef juice may be begun in 
the ninth or tenth month, earlier with anemic children; at first not 
more than two teaspoonfuls daily, later the amount may gradually be 
increased to one ounce. The best fruit juice is that of the orange, which 
should be fresh and sweet. It may with advantage be given to all healthy 
infants eight months old, and to most when six or seven months old. 
Beginning with half an ounce, the quantity may gradually be increased 
to two ounces daily, given preferably about one hour before the second 
milk-feeding. 

The Tolerance of Healthy Infants for the Different Food Elements. 
— In the foregoing pages we have indicated the proportions and amounts 
which, in our experience, have been shown in the majority of instances 
to be the best for feeding healthy infants. However, Nature will often 
tolerate quite wide variations from what is best. The desire for a rapid 
increase in weight often leads to an increase of the fat in the food much 
beyond the limits which are usually safe. There are some children of 
vigorous constitution and strong digestion, living in good surroundings, 
who tolerate this for a long time; some may even go through infancy 
to a period of mixed diet without any visible disturbance, and appear 
to thrive exceedingly well. There are others who bear for a consider- 
able time very high proportions of carbohydrates and show phenomenal 
gains in weight. In both the conditions mentioned tolerance usually 
breaks down after a time, often from a trivial cause. This may be some 
intercurrent illness like a cold or a mild bronchitis, or the advent of very 
hoi weather; or, sometimes even so slight a thing as dentition may bring 
about an upset of a most alarming character. In other children there 
gradually develop subacute or chronic disturbances of digestion and 



200 NUTRITION 



nutrition which may last for months. One should be very cautious, 
therefore, in inferring that because a few infants thrive on unusual pro- 
portions or excessive amounts of some one of the food elements this is 
to be taken as a guide in feeding the average child. 



FEEDING IN DIFFICULT CASES 

In the aggregate the number of infants included under the head of 
"difficult feeding cases" is a large one, and their management constitutes 
the most "special" branch of Pediatrics. The problem is often one of 
great complexity, the symptoms presented are of almost endless variety 
and even one of large experience often finds himself baffled. Let no 
one, therefore, expect to solve these problems without careful study of the 
individual cases and the closest attention to detail. 

Causes. — In some of these infants difficult feeding is due to feeble 
digestion or some individual peculiarity because of which they do not 
thrive, even from the outset, upon the usual milk modifications although 
used intelligently. In a much larger group the cause is to be found 
in prolonged disturbances of digestion, the result of previous improper 
methods of feeding. The difficulties are greatest in early infancy, in 
cities, in institutions, in hot weather, and they are further increased 
by the existence of constitutional debility, and when -the trouble is of 
long standing. It is not infrequently found that the failure is due not 
to any fault with the food prescribed, but to other conditions. The food 
may be improperly prepared or given — e. g., it may be cold or given 
too rapidly ; the bottles or nipples may be dirty ; the proper quantities 
and intervals not observed, etc. Another factor of importance is the en- 
vironment as affecting the nervous system of the infant. Among the 
well-to-do this may be the chief trouble. The constant or frequent ex- 
citement by visitors, or playing with a child by parents or nurses, may 
result not only in lack of sleep, but in disturbances of digestion, often 
in habitual vomiting, though the food itself is proper. In such cir- 
cumstances the removal of the child from its surroundings or placing 
him in charge of a competent nurse will often cause an immediate and 
marked improvement without any change in the food. Another minor 
cause of disturbance is the habitual use of the "pacifier," frequently 
resorted to in these cases, but which should under no conditions be tol- 
erated. 

That a prolonged disturbance of digestion in a young infant is a 
serious thing is often not appreciated. The mother is apt to think the 
problem one easy of solution; she "only wants to be told what to feed 
her baby," imagining that a single food prescription should set the child 



FEEDING IN DIFFICULT CASES 201 

right at once. The physician too, sometimes, regards the condition 
lightly because these infants do not seem really ill; he therefore con- 
siders the subject hardly important enough for his careful, continuous 
attention. The fact should be emphasized that these cases are serious, 
that they are difficult, that in most of them nothing can be accom- 
plished without close and continuous personal observation, that they do 
not tend to right themselves, and that infants' lives are often sacrificed 
as a result of bad management. 

Clinical Types. — The greater number of these cases may be divided 
into three groups: (1) those whose chief symptom is habitual vomiting, 
or regurgitation of food; (2) those with intestinal symptoms, most 
frequently with loose stools; (3) those without any marked symptoms 
of indigestion, yet whose weight is much below the average, who do 
not gain on weak food and are upset if stronger food is used. They 
have feeble digestion rather than indigestion. 

Cases with Vomiting. — The causes producing this are usually rather 
obvious. When cream and milk mixtures or top-milk mixtures are 
used, altogether the most frequent mistake is the use of too much fat. 
The amount used may not be more than many healthy children will 
take, but it is excessive for the particular patient. It is surprising- 
how great the intolerance to fat is in some of these infants and also 
when once established how long it persists. Another frequent cause 
is the use of too much cane sugar, milk sugar, or one of the proprietary 
foods containing maltose or much starch. Other factors of importance 
are too frequent feedings, too much food and the use of unsuitable and 
indigestible foods. The vomiting may also be the result of a neuropathic 
constitution. (Page 262). The condition may be a sequel of any of 
the acute infections and is more intractable in the course of a severe 
constitutional disease such as rickets, syphilis or tuberculosis. 

With such severe and prolonged symptoms as are often present, patho- 
logical changes in the stomach might be expected. These, however, are 
strikingly absent. The stomach may be slightly dilated and there is 
usually a large amount of mucus present but macroscopically and even 
microscopically there are no important or even constant changes. 

The most important symptom is vomiting. It may occur soon or 
long after feeding. Some of these infants vomit only occasionally and 
in large quantities; but it is more common for frequent regurgitation 
of small amounts of food to take place. This may begin soon after one 
feeding and continue quite to the time for the next. After a time, the 
vomited matters nearly always contain mucus, and sometimes this is a 
conspicuous feature. The regurgitation of a sour irritating fluid occurs 
even when but little food is ejected, and usually accompanies the belch- 
ing of ffas. 



202 NUTRITION 

The results obtained in the examination of stomach contents have not 
been uniform, and in practice one should not lay much stress upon 
the absence of the noTmal secretions. The presence of mucus in the 
vomited matters or in the washings from the stomach is nearly a con- 
stant feature. This greatly interferes with digestion, even though the 
secretions are normal. The reaction of the stomach is almost always 
acid. The hydrochloric acid is almost invariably diminished in quan- 
tity. Free hydrochloric acid is very seldom present. There is usually 
a marked odor of butyric and other volatile fatty acids. One would 
expect, therefore, to find these in excess, but the studies of Huldschinsky 
have shown that they are little if at all increased in the stomach con- 
tents of vomiting infants. The rennet ferment and pepsin are almost 
invariably present in normal amount, hence the administration of di- 
gestive ferments is not indicated. 

In addition to air which is swallowed, there is an increased pro- 
duction of gas. Some of the most striking symptoms are due to dis- 
tention. The epigastrium may be tense and hard most of the time, and 
often so much gas is present that infants find difficulty in taking food. 
Though evidently hungry, they can take so little at a time that an 
hour or more may be required to take four or five ounces. There is 
motor insufficiency of the stomach and probably in some cases a certain 
degree of pyloric spasm which causes gastric stagnation. That the 
food remains long in the stomach is best demonstrated by aspiration 
or stomach-washing. Instead of the stomach's being empty in two and 
a half or three hours, as it should be, food may be found four or five 
hours, and in some cases six or eight hours, after feeding. There 
may be dilatation of the stomach, especially in older infants who are 
rachitic. 

The appetite may be abnormally great, or it may be poor. As a rule, 
children take less food than in health. The tongue is usually coated. 
The general symptoms are those of malnutrition ; there is constant fret- 
fulness, and sleep is irregular or disturbed; the weight is stationary, or 
there is a steady loss; there is also anemia, and the child's development 
is arrested. There is nearly always some derangement of the bowels, 
more often constipation than diarrhea. 

Infants who vomit as the result of a neuropathic constitution may 
show at first no symptoms but the vomiting. If this is severe and con- 
tinued, later they show evidences of malnutrition, sometimes of an ex- 
treme grade. 

There is little tendency to spontaneous improvement or recovery, 
the prognosis depending almost entirely upon the treatment employed. 
Unless relieved the condition is apt to continue, until sonic serious 
acute disease develops which may be fatal. In very young infants 



FEEDING IN DIFFICULT CASES 203 

such gastric disturbances should not be confounded with hypertrophic 
stenosis of the pylorus. 

In the treatment, the question of diet is of first importance. It is 
the chief therapeutic measure. The indications for varying the quality 
and quantity of the food when there is habitual vomiting have already 
been discussed (page 193). The feedings should be at least four hours 
apart and the amounts smaller than normal infants of the same age 
would receive. The usual practice when an infant suffers from vomiting 
is to dilute his food and, in some instances, this is perfectly proper ; but 
to continue increasing the dilution because the patient does not do well 
may be the very worst treatment. Small feedings, not weak food, are 
what benefit some of these children most, the balance of the daily amount 
of water needed by the infant being given between the feedings. Unless 
cream or top-milk mixtures have been employed the sugar is more likely 
to be the exciting cause of the vomiting than any other ingredient of 
the food. This should be greatly reduced in amount or temporarily re- 
moved altogether. When the vomiting has ceased the sugar may grad- 
ually be increased. Milk sugar is less likely to ferment in the stomach 
than cane sugar or maltose. The latter should never be used with vomit- 
ing infants. Buttermilk, on account of its low fat and moderate sugar 
content, is frequently of value, but it cannot advantageously be continued 
very long without the addition of carbohydrates in some form. The very 
factors that make it of value for temporary use make it disadvantageous 
for permanent use. 

Wet nursing does not bring immediate improvement in the vomit- 
ing and sometimes none at all. The large amount of sugar and fat in 
breast milk sometimes aggravates the symptoms. Usually, however, the 
infant when breast-fed improves; but the vomiting may continue so 
severe as to make it necessary to return to artificial feeding. When 
the vomiting has ceased, however, nothing brings about such rapid re- 
cuperation of the general health as does breast milk. 

At times, nothing succeeds so well as giving semi-solid food with 
the spoon. Cereals cooked with milk as described on page 263 are read- 
ily borne by many infants, especially those with vomiting due to nervous 
causes. 

Stomach washing is frequently useful, especially with persistent cases. 
It removes the mucus, cleanses the organ and acts as a stimulant to the 
gastric secretions, especially the hydrochloric acid. Plain boiled water, 
or a weak alkaline solution — sodium bicarbonate, one dram to the pint 
— may be employed. In the early part of the treatment the washing 
should be done daily; later, every second or third day. The time se- 
lected is not of great moment, but it is better to make this about three 
hours after feeding. 



204 NUTRITION 

The general treatment is apt to be ignored, but is important. The 
best possible hygiene should be secured, — a large, roomy nursery, and 
plenty of fresh air by night and by day; equally necessary are quiet 
surroundings and freedom from disturbing conditions which sometimes 
obtain in the nursery. General friction of the body is useful in delicate 
children with poor circulation. Infants must be properly covered, and 
it is of the utmost importance that the feet be kept warm. 

Drugs have a very limited application in the treatment of this con- 
dition in infants. They have been too much used, and too little atten- 
tion has been given to the details of feeding, by which means alone 
permanent improvement is usually reached. The continued use of pepsin 
and other digestive ferments is irrational and without benefit. Hydro- 
chloric acid may at times prove of value, but it must be given in rather 
large doses, — i. e., five to fifteen drops of the dilute acid after each 
feeding. 

Cases with Intestinal Symptoms. — These are found most frequently 
in infants born prematurely, in those with constitutional debility, who 
have never been vigorous, in those brought up in poor surroundings with 
unintelligent care or in those who have suffered from any acute disease, 
especially inflammation of the gastro-intestinal tract, such as ileoco- 
litis. Usually there has been artificial feeding from the beginning or 
after a few weeks of nursing. Some of the infants also belong to the 
neuropathic type. To the extent that it is usually avoided by maternal 
nursing, the condition is a preventable one. But there are a few infants 
that develop these symptoms even while nursing ; and a considerable 
number, in spite of intelligent artificial feeding. There seems to be with 
these infants a particular lack of resistance on the part of the intestinal 
tract. It never seems capable of accomplishing the work devolving upon it. 

In infants fed on top-milk mixtures, the most common cause of dis- 
turbance is an excessive amount of fat. When whole-milk modifications 
are used the fault is usually an excess of sugar, and with older infants 
too large quantities of farinaceous foods, often insufficiently cooked. 
The carbohydrates may not be more than the average child takes well, 
but these infants are particularly sensitive. 

There are no constant or characteristic pathological changes. There 
may be a hyperplasia of the lymphoid tissue of the intestines and some- 
times there is a similar process in the mesenteric lymph nodes. Usually, 
however, these are absent. 

The symptoms are general and local. So far as the intestinal con- 
dition is concerned, diarrhea is the most frequent and serious symp- 
tom. It may happen that the same child will suffer for a long time 
from diarrhea and then from constipation, but the constipation is usually 
the result of dietetic measures directed against the diarrhea, — i. e., a 



v b ^^^v KUV ^xnxxx^M,, 



FEEDING IX DIFFICULT CASES 205 

reduction in the fat or the carbohydrates, or both. As a result, the 
energy value of the food is reduced to a point at or below the main- 
tenance requirement. 'When, in order to produce gain in weight, these 
substances are increased in the food, diarrhea again results. There may 
thus be over long periods, alternating constipation and diarrhea. The 
stools are of all varieties, depending on the severity of the symptoms and 
the character of the food. They are usually more frequent than normal 
and generally contain undigested food and mucus. In some cases the 
stools contain but little solid matter, the character being that of yellow- 
ish-green water. The stools usually have a sour, unpleasant odor, but 
are rarely very foul. They may be irritating to the skin and cause 
troublesome excoriations and intertrigo. There may be much gas and 
flatulence. 

If there is constipation, the stools are usually gray or white; they 
are smooth and pasty like hard balls and passed after much straining, 
often coated with mucus and sometimes streaked with blood. Such 
stools are not infrequently seen when the food contains a large amount 
of fat. With the constipation there may be much flatulence and colic, 
the attacks of which may be severe. 

The general symptoms are those of malnutrition. These are more 
fully described elsewhere and need only be mentioned here. The most 
important are: stationary or falling weight, anemia, poor circulation, 
often subnormal temperature, almost constant fretfulness and crying, 
with very little quiet sleep. The tongue may be coated but more often 
is quite clean. The appetite is frequently good, these infants taking 
food whenever given, and in an almost unlimited quantity. There are 
few cases in which occasional vomiting does not occur, sometimes it is 
marked and persistent, but it is rare for it to be so. When so much of 
the food is regurgitated by vomiting, as in the cases just described, the 
intestinal tract, even with highly erroneous methods of feeding, is thereby 
protected. 

The duration of these symptoms is indefinite. Even with the great- 
est care there is little or no tendency to spontaneous improvement. They 
may drag on for many months with frequent exacerbations and remis- 
sions. The symptoms may be relieved, but at the same time to insure 
growth and a gain in weight may be, for the time being at least, well 
nigh impossible. The least increase in the food, especially the carbo- 
hydrates or fats, may be sufficient to precipitate an attack of diarrhea 
with further loss in weight. Thus, there may alternate slight gains and 
losses, the weight for months being nearly stationary. 

A danger to these patients is that of intercurrent infections. To a 
delicate infant an attack of rhinopharyngitis with otitis may be more 
serious than a frank pneumonia to a vigorous child. Any infection is 



206 NUTRITION 

to be feared, bronchitis and pneumonia particularly so. Death seldom 
results from the severity of the condition itself. With appropriate treat- 
ment a gain in weight usually results, although this may be delayed 
many weeks or months. With infants over six months of age the prob- 
lem is usually an easier one than with those younger. Especially is 
there difficulty with premature infants and those much under weight at 
birth, i. e., five pounds or less. 

Drugs have no part in the treatment of these cases; in nearly every 
instance they had best be omitted altogether. The treatment is die- 
tetic. Prophylaxis is important. Maternal nursing will <do much to 
prevent the development of such cases. It is necessary to obtain a 
careful and minute history in order to direct matters intelligently. The 
previous feeding should be thoroughly known, the different changes made 
and their effect upon the intestinal symptoms and the infant's weight. 
With this information one can often at once determine where mistakes 
have been made and in many instances it is found that the same mistake 
has been repeated with each change of food. 

Occasionally diarrhea develops with maternal nursing and it is by 
no means infrequent when, on account of a tendency to attacks of diar- 
rhea, wet nursing is resorted to. The cause of this is the large amount 
of fat and sugar in breast milk, both of which readily undergo change 
in the intestines with the production of irritating lower fatty acids. 
Breast feeding should not be interrupted under such circumstances but 
supplementary feeding with a food low in fat and sugar should be re- 
sorted to. The most available food is buttermilk. This may be given at 
alternate feedings or may be given in amounts of one or two ounces 
just before the nursing. When the symptoms have been overcome, the 
buttermilk may gradually be withdrawn from the dietary. Breast 
feeding is altogether the safest method of treating such conditions in 
those infants under three months of age. Many of those older may be 
successfully treated by artificial feeding but progress, in order to be sure, 
must be slow. In protracted cases minor variations in the composition 
of the food or in the plan of feeding rarely accomplish much. The 
most brilliant results are often obtained from as complete a change in 
the diet as possible. Notwithstanding the fact that these patients are 
usually much below the normal weight and often losing steadily, the 
treatment should be directed first of all to allaying the most marked in- 
testinal symptoms. Until these are relieved, no permanent improve- 
ment can be expected. For the time being, the weight must be dis- 
regarded. 

So far as the elements of cow's milk are concerned, the greatest 
difficulty is seen when both fat and sugar are given in considerable 
amount. A moderate amount of fat with a minimum of sugar usually 



FEEDING IX DIFFICULT CASES 207 

causes no diarrhea. Sugar, however, even in the absence of fat, will 
produce it. For this reason, the use of skimmed milk and even fat-free 
milk usually causes no improvement in the diarrhea, there being too much 
sugar in fresh milk, even without the addition of any extra amount. 
Top-milk or milk and cream mixtures are not admissible. If fresh milk 
mixtures are to be used, dilutions of whole milk or of partially skimmed 
milk should be given, with no carbohydrates added. If, upon this diet 
the stools become normal, sugar may gradually be added, but this must 
not be lactose or a mixture in which maltose is present in a large amount, 
such as malt soup. The dry preparations of maltose or cane sugar 
should be at first tried and in small quantity, not over one teaspoonful 
daily. 

If fresh milk mixtures are not well, borne, buttermilk and other fer- 
mented milks may be tried. These succeed in a certain number of cases 
that do not respond to skimmed milk. It is seldom necessary to dilute 
them more than with an equal amount of water. Additional carbo- 
hydrates needed may, after a time, be supplied — best by adding starchy 
food w T ith small quantities of cane sugar. 

Protein milk is one of the most valuable of the recent additions to 
our resources in feeding cases of this type. The chief advantages here 
are apparently due to its low sugar content, for it contains a consider- 
able amount of fat, indicating that fat in the absence of carbohydrates 
is very frequently well borne. The large amount of protein which 
readily undergoes putrefaction inhibits the formation of the lower fatty 
acids from the carbohydrates and fats. Only for very young infants 
need it be diluted and it is seldom necessary to reduce the fat by making 
it from skimmed milk. Not much gain in weight is seen when protein 
milk is used alone. Carbohydrates should be added as soon as possible, 
but always with great caution, beginning with very small quantities. 
Cane sugar should first be tried, then one of the dry preparations of mal- 
tose beginning with not more than a half tablespoonful daily and slowly 
increasing. 

Either of these sugars may be used in conjunction with starchy food 
which may be wheat or barley flour from one-quarter to one ounce daily, 
the latter amount to children five or six months of age. Employed in 
this way protein milk may often be continued for two or three months, 
but without the addition of carbohydrates it is seldom advantageous 
for more than two or three weeks. 

Peptonized milk has been altogether too frequently employed and 
offers no aid in the treatment of intestinal conditions. A change to a 
diet other than milk should be made very slowly and with great care; 
one relatively rich in carbohydrates is usually badly borne. Carbo- 
hydrates in the form of cooked cereals must be added gradually. Eggs 



208 NUTRITION 

are sometimes of assistance and junket is frequently of value in pre- 
venting excessive fermentation. Solicitous care should not cease with 
these children at the end of the first year, they must be closely watched 
until they are three or four years old. 

The same careful hygiene is as important as in patients with gastric 
symptoms. The general methods employed should be the same. 

Cases with Feeble Digestion. — Infants whose digestion is very feeble, 
although they have neither pronounced gastric or intestinal symptoms, 
are very difficult patients to feed. Gains in weight are very slow and 
one must be content if any regular gain takes place. In case of failure 
by the usual milk modifications, wet-nursing is altogether the most suc- 
cessful form of feeding. Sometimes it is sufficient if only partial breast 
feeding can be given, i. e., three or four feedings a day. This is a plan 
of much value in institutions and saves many babies. If no breast feed- 
ing is possible, artificial feeding must be conducted in the most pains- 
taking manner lest serious digestive upsets occur. If these can be 
avoided it usually happens that as the child grows older and a more 
varied diet can be given, the problem grows steadily easier. 

With some infants, in the event of failure by the usual methods, the 
first start, which is really the most difficult one, may be made upon 
sweetened condensed milk which is diluted with plain water or barley 
water. "Evaporated" or unsweetened condensed milk has at times suc- 
ceeded when fresh whole milk has failed. The explanation for this can- 
not be given. Unsweetened condensed milk requires the same addition 
of sugar and starch as does whole milk. 

When there is no vomiting and no tendency to diarrhea, feeding with 
considerably higher proportions of carbohydrates than are usually em- 
ployed is also sometimes useful for a short time. It may be carried out 
with fresh milk as in the various malt-soup mixtures, or with sweetened 
condensed milk or evaporated milk as a basis. When an excess of carbo- 
hydrate is given the percentages of fat and protein, but especially the 
former, should be lower than in the usual formulas for the age and 
condition. There is apparently some advantage in using a variety of 
sugars; a combination of lactose, maltose and cane sugar being given 
rather than any one of them alone. The total sugar may sometimes be 
carried above 7 per cent but always with caution. Starchy food is added 
in the form of barley, wheat or oat flour, cooked for ten to twenty min- 
utes. The daily quantity used may be from half an ounce to two ounces 
according to age and condition. The larger quantity mentioned may 
sometimes be given to an infant of five or six months. With infants 
over six months of age thick gruel like that advised for normal infants 
of ten or twelve months may be of great assistance in causing gain in 
weight. 



HEALTHY INFANTS DURING THE SECOND YEAR 209 

A diet containing an excessive amount of carbohydrate is not adapted 
to prolonged use and incautiously used may be followed by serious upsets. 
For a time all may go well; then from some apparently trivial cause a 
breakdown occurs. As soon as possible the child should be placed upon 
a more rational food, i. e., a properly "balanced ration" by introducing 
at first one and then other feedings from whole milk modifications in 
which fat and protein are raised and carbohydrates reduced. 

A foodstuff occasionally useful is olive oil. It is a form of fat which 
can sometimes be tolerated when the fat of cow's milk habitually dis- 
agrees. The amount used at first should be small, not more than one-half 
teaspoonful twice a day. The maximum amount to be used for infants 
of the first year should not be over two teaspoonfuls daily. 

The chief means by which weight can be increased in children suffer- 
ing from malnutrition is therefore through the addition of carbohydrates, 
especially maltose, as soon as these can be tolerated ; next by the addition 
of fat, but neither of these is to be employed in any considerable quantity 
until the marked symptoms of indigestion have been controlled. 



CHAPTEE IV 
FEEDING AFTER THE FIRST YEAR 

HEALTHY INFANTS DURING THE SECOND YEAR 

The physician should not relax his vigilance in the feeding of a 
child after the first year has passed. The ideas of the laity in regard to 
what is proper for a child after he has outgrown an exclusive milk diet 
are very erroneous. Most of the disorders of digestion of early childhood 
are directly traceable to dietetic errors. Among the poor the majority of 
infants are given solid food too early, in too large quantities and improp- 
erly prepared. Among many of the intelligent and well-to-do the dis- 
position is to go to the opposite extreme and to keep the infant too long 
upon a diet composed exclusively or almost exclusively of milk. 

During the second year the diet of a healthy child should consisl 
chiefly of milk, bread, farinaceous foods, fruit juices or cooked fruit, with 
a small amount of animal food in the form of beef juice, broths, meat 
and eggs. By the middle of the year with most children, with some even 
earlier, potato may be added, also green vegetables, at first in small quan- 
tities, thoroughly cooked and pureed. 

Milk should be the largest item of the diet, but when solid food in 
any considerable quantity is begun it should be reduced; few children 



210 NUTRITION 

require more than a pint and a half of milk a day. The popular notion 
that there are many children who cannot take milk is an erroneous one ; 
the real trouble usually is that too rich milk is given or that the quantity 
allowed is too large. It is often drunk like water with a hearty meal of 
other food and the child is simply overfed. On the other hand, to permit 
a child to give up milk altogether because solid food pleases the palate 
better is a mistake. It is important, however, that the transition from 
an entirely fluid diet to one of solid food should be made gradually, and 
that the habit of taking milk should not cease at the end of the first, or 
even the second year. 

During the second year with average milk and average infants no 
modification of the milk is required. If the milk is very rich, such as 
that from a Jersey herd, it should be partially skimmed or diluted with 
at least one-fourth water. In hot weather especially should these meas- 
ures be insisted on. 

Weaning from the Bottle. — This should always be begun before a 
child is a year old ; by the thirteenth month an infant should take all his 
milk from a cup, except possibly the 10 p. m. feeding, when for the sake 
of convenience the bottle may be allowed. Early weaning from the bottle 
is a matter of no small importance. When the bottle is allowed to older 
children the temptation to overfeeding, especially during the summer, 
may be very great. Again there are many children with the "bottle- 
habit" -so firmly developed that throughout childhood, although at any 
time they will take milk from the bottle, they can never be induced to 
take it any other way, and sometimes refuse all other food so long as the 
bottle is allowed. 

From Twelve to Fifteen Months. — The daily schedule at this period 
should be about as follows : 

6 to 7 a.m. Milk, six ounces, diluted with two to three ounces of barley or oat 
gruel. 
9 a.m. Orange juice, one to three ounces. 

10 a.m. Cereal (thoroughly cooked and strained), one large tablespoonful. 
Milk, six ounces, part of it on cereal. 
Crisp, dry toast, one piece. 
2 p.m. Beef juice, one to two ounces; 

or, mutton or chicken broth, three to four ounces; 
or, one-half, later one entire soft egg. 
Crisp, dry toast or unsweetened zwieback, one piece. 
Milk and gruel in the proportions given above, four to six ounces. 
6 p.m. Same as at 10 a.m. 
10 p.m. Same as at 6 a.m., but given from a bottle. . 

In preparing the food, the milk and the gruel are simply mixed 
together while the latter is warm; salt and at first a very small quantity 



FEEDING FROM THE THIRD TO THE SIXTH YEAR 211 

of cane sugar are added to make it palatable. It is then divided into as 
many feedings as are required for the day, each one being placed in a 
separate bottle. As to handling the bottles and pasteurizing or steriliz- 
ing, the same rules apply as during the first year. 

From Fifteen to Twenty Months. — The diet may be increased by the 
addition of more solid food. The average child will require : 

6.30 a.m. Milk, warmed, eight ounces. 

9 a.m. Orange juice, two to three ounces. 

10 a.m. Cereal, two good tablespoonfuls, oatmeal or hominy, cooked three 
hours, not strained, with one ounce of thin cream or top-milk. 
Milk, six ounces. 

Crisp toast or zwieback, one or two pieces. 
2 p.m. Beef juice and two teaspoonfuls of scraped meat; 
or, broth, four ounces, and one egg. 
One-half of a baked potato; 

or, one tablespoonful of a green vegetable (spinach, carrots, fresh 
peas, string beans, asparagus tips) thoroughly cooked and put 
through a fine sieve. 
Stewed prunes, three or four; 

or, one-half a baked apple, strained. 
Crisp toast or dried bread. 
6 p.m. Cereal, two tablespoonfuls, farina or cream of wheat, cooked one hour, 
served as at 10 a.m. 
Milk, eight ounces. 
10 p.m. Milk, six ounces (omitted at eighteen months and sometimes earlier). 

From Twenty Months to Two Years. — By the end of the second year 
the amount of the solid food, especially the quantity of meat and vege- 
tables, may be somewhat increased. The meat allowed may be finely 
minced or seraped beefsteak, lamb chop or chicken. Only four meals 
should be given, the 10 p. m. feeding being omitted, and nothing but 
water between the feedings ; this, however, should be allowed freely. Raw 
fruit except orange juice should not be given. It is usually better to give 
the fruit and milk at different meals. It is often more convenient to 
transpose the morning feedings, giving the milk at 10.30 and the prin- 
cipal meal at 7.00 or 7.30 a. m. 



FEEDING FROM THE THIRD TO THE SIXTH YEAR 

Articles Allowed. — From the following list the diet of a healthy (hi Id 
may be arranged. 

Milk. — This should form a prominent part of the diet. No child 
requires more than a pint and a half (three glasses) daily. Rich Jersey 
milk should not be chosen. The milk should usually be given warm. 



212 



NUTRITION 



Cream. — Not more than three or four ounces of thin (16 or 20 per 
cent) cream should be given daily. It should not be used upon fruits, 
especially sour fruits. It may be used upon cereals, upon potato and in 
broths. Cream should not be given at all to children who suffer from 
so-called bilious attacks, with coated tongue, bad breath, etc. 

Eggs. — They should be fresh, soft-boiled, poached, coddled, or scram- 
bled, but not fried. Children vary greatly as regards their ability to 
digest eggs ; many children will take two eggs a day, some only one, and a 
few can not take them at all. 

Meats. — Some form of meat should be given once a day. The best 
are beefsteak, lamb chop, and roast beef or lamb and the white meat of 
chicken; next to these certain of the more delicate kinds of fresh fish, 
which should be boiled or broiled. Beef and lamb should be given rare. 
All meat should be very finely divided. Cold meat should be avoided. 

Vegetables. — Potato may be given once a day, baked or mashed, with 
the addition of cream or beef juice rather than butter. Of the vegetables 
the best are asparagus tips, spinach, stewed celery, string beans, carrots, 
and fresh peas. One of these vegetables should be given daily — always 
well cooked and mashed. 

Cereals. — None of the "dry" or ready-to-serve cereals should be given 



CALORIC VALUES OF COMMON FOODS 



Cereals (cooked). 


Ounce. 
18 
22 
16 
32 
26 


Even 
Tablesp'l 
10 
10 
7 
17 
15 




Ounce. 
6 




Broth . . 


5 


Farina 




30 






40 






15 




Milk 


20 




22 
33 
6 
17 
16 
14 
33 
58 


13 
16 

3 
10 
10 

9 
17 
30 


Cream (20%) . . 


60 






100 






15 










One slice of bread, 4 x 4 x 3^ in . . . 


80 




100 






25 






75 






100 






75 






50 


Butter 


225 

146 

116 

50 

32 


114 
38 
32 
22 
16 




100 






100 








Lean roast beef, lamb or chicken . 
Fish 









In ordering a diet for children a knowledge of the nutritive or caloric value 
of the different common articles of diet is highly desirable. 

As estimated in the table, vegetables are finely mashed, meats are finely 
divided and even tablespoonfuls are tightly packed. 

Cereals are cooked in water in proportions given on the package, i.e., oat- 
meal one cup to water one pint. 



FEEDING FROM THE THIRD TO THE SIXTH YEAR 213 

to young children. They are the cause of more disturbances of digestion 
than almost any other common article of diet. Almost any cereal which 
has been thoroughly cooked may be allowed — oatmeal, wheaten grits, 
hominy, rice, cornmeal, farina, and arrowroot. If the grains are used, 
cereals should be cooked from three to six hours, after having been pre- 
viously soaked. The partially cooked cereals of the shops should always 
he cooked two or three times as long as the directions upon the package. 
The "tireless cooker" is an excellent device for the proper cooking of 
cereals for children. Cereals should always be well salted, and given with 
milk or cream, but with little or no sugar. 

Broths and Soups. — Both meat and vegetable soups may be given and 
nearly all varieties of the latter except tomato soup. Plain broths are not 
very nutritious, but when thickened with arrowroot or cornstarch, and 
when milk is added, they are very palatable, and at the same time a val- 
uable addition to the diet. Most vegetable purees are useful, and when 
properly made very digestible. Beef juice may be used as directed for the 
second year. 

Bread and Biscuits (Crackers) . — In some form these may be given 
with nearly every meal, better without butter until the third year. All 
varieties of bread may be allowed when stale — i. e., two or three days old; 
also dried bread, zwieback, and oatmeal or gluten crackers. 

Desserts. — The only ones besides cooked fruits that should be allowed 
up to the sixth year are junket, plain custard, rice pudding without 
raisins, and, not oftener than once a week, ice cream. Of the last three, 
the quantity given should be very moderate. 

Fruits. — Some fruit should be given to most healthy children every 
day. Oranges, baked apples, and stewed prunes are the most to be 
depended upon. Paw apples should not be given in most cases. Peaches, 
pears, and grapes (with seeds removed) may be given when thoroughly 
ripe and fresh, but only in moderate quantity. The pulpy fruits should 
be given to young children only when cooked. Much indigestion is pro- 
duced by too much fruit or improper fruits. Special care should be 
exercised in the use of fruits in very hot weather, and in cities where 
they may not always be fresh. The juice of fresh berries may be given 
in the second year; but the whole fruit should be very sparingly given to 
all young children, and always without cream. 

Articles Forbidden. — The following articles should not be allowed 
children under four years of age, and with few exceptions they may be 
withheld with advantage up to the seventh year : 

Meals. — Ham, sausage, pork in all forms, salt fish, corned beof, dried 
beef, goose, duck, game, kidney, liver, meat stews, meat dressings and 
cold meats. 

Vegetables. — Fried vegetables of all varieties, cabbage, raw or fried 



214 NUTRITION 

onions, raw celery, radishes, lettuce, cucumbers, tomatoes (raw or 
cooked), beets (unless they are very small and quite fresh), egg-plant, 
and green corn. 

Bread and Cake. — AH hot bread and rolls; buckwheat and all other 
griddle cakes; all fresh sweet cakes, particularly those containing dried 
fruits and those heavily iced. 

Desserts. — All nuts, candies, pies, tarts, and pastry of every descrip- 
tion; also all salads, jellies, syrups, and preserves. 

Drinks. — Tea, coffee, wine, beer, cider, and soda water. 

Fruits. — All dried fruits; bananas, unless baked; all fruits out of 
season and stale fruits, particularly in summer. 

From the third to the sixth year four meals should usually be given 
daily and at regular intervals — e. g., 7 and 10.30 a.m. ; 1.30 and 6 p.m. 
The second meal should be a small one. 

There are a few simple rules in feeding which should always be fol- 
lowed : A child should be taught to eat slowly and thoroughly' masticate 
his food. The food must always be very finely divided, for mastication 
is very inrperfect even up to the sixth or seventh year. It is unwise 
continually to urge children to eat when they are disinclined to do so 
at the regular hours of meals, or when the appetite is habitually poor, 
and in no circumstances should children be forced to eat. Indigesti- 
ble articles of food should not be given to t&npt the appetite when ordi- 
nary simple food is refused. Food should not be allowed between meals 
when it is habitually declined at meal-time. If a child refuses to eat, 
and examination reveals no fault with the food prepared, it should sel- 
dom be offered again until the next feeding time. In all cases of tem- 
porary indisposition, no matter of what nature, and during periods of 
excessive heat in summer, the amount of solid food should be reduced 
and more water given. If milk is the food, it should be diluted. 



FEEDING DURING ACUTE ILLNESS 

Infants. — Feeding is an important part of the treatment of every 
acute disease in childhood, but especially so in infancy. Unless the ill- 
ness is due to disease of the digestive tract, all cases must be fed in about 
the same way. It is much easier by proper feeding to prevent disturb- 
ances of digestion than to allay them. In infancy this complication often 
turns the scale against the patient. In every severe acute illness, espe- 
cially if it is of a febrile character, the power of digestion is much dimin- 
ished. One evidence of this is the onset with vomiting; another is the 
anorexia which accompanies the early stage of nearly all acute diseases. 
We should respect this disinclination and make it our guide in the treat- 



FEEDING DURING ACUTE ILLNESS 215 

Blent. But water is needed ; withholding this will often cause the tem- 
perature to rise eveu higher than before. 

In all acute febrile diseases the general rule should be, less food and 
more water than in health. For bottle-fed infants this is easily accom- 
plished by simply increasing the dilution of the food ; for nursing infants 
by making the nursing time shorter and giving water freely between 
feedings either from a spoon or bottle. During febrile conditions, fat, 
especially, is badly borne, and this should therefore be reduced more than 
the other elements of the food. The diet should consist largely of carbo- 
hydrates. 

Regularity in feeding is too often entirely ignored. While it is true 
that with some capricious children all rules must be disregarded, it is 
with the great majority a decided advantage to adhere to proper food 
and regular intervals. Food should never be given at less than three- 
hour intervals, although there is no limit to the frequency with which 
water may be given, and unless the stomach is irritable, almost no limit 
as to quantity. Stimulants, when required, are often best given in a 
very dilute form with the water. 

Forced Feeding — Garage. — Not a few cases, however, are seen in 
which, after a child has been several days sick, in consequence of delirium, 
stupor, sepsis, or some other serious condition, he may refuse all food or 
take so little that he is in danger of death from inanition. At this junc- 
ture forced feeding or gavage serves an excellent purpose. Both food 
and stimulants can thus be introduced at regular intervals with slight 
disturbance, and lives saved which would otherwise be lost. If gavage 
js employed, the stomach should be washed at least twice a day. The 
intervals of feeding should be made at least one hour longer than is cus- 
tomary in health. Forced feeding is not applicable to chronic conditions. 

Older Children. — The same conditions with reference to digestion 
exist as in the case of infants. Older patients, however, are not so easily 
disturbed, and the disturbance of digestion is not so likely to be serious 
as in the case of infants. Even here the physician should direct the food 
to be given at regular intervals, not oftener than every three hours, 
and should never — as is so often done — order that milk be given the 
child every time he asks for a drink. In most cases, for children under 
five years old, milk should be somewhat diluted. Children who do 
not take milk readily may be given beef tea, broth, gruel, thin custard, 
of kumvss, and occasionally plain ice cream, but this, if given in any 
considerable quantity or very often, is likely to disturb the stomach and 
take awdy what little desire for food the child may have. Raw eggs are 
palatable when beaten up with a little sherry, sugar, and cracked ice. 
Fruits, especially orange and grape juice, may be allowed in almost ever} 
febrile disease, but not given within two hours of a milk feeding. 



216 NUTRITION 

The water given may be plain boiled water, but often better, are some 
of the carbonated waters, Vichy, Seltzer, or Apollinaris, these being less 
likely to disturb the stomach. 

It is certainly a mistake to force food upon older children in any 
disease in which their condition is not dangerous. But when there is 
sepsis, delirium, or coma associated with other dangerous symptoms, 
gavage may be resorted to with but little more difficulty, and with no less 
satisfactory results, than in infants. 



IDIOSYNCRASIES TO FOODSTUFFS 

It is only in recent years that there has been demonstrated an idiosyn- 
crasy on the part of some children to certain foodstuffs, in all probability 
to the protein of the foodstuffs and to this alone. 

The most conspicuous example is the proteins of egg. Some children 
are so sensitive to egg proteins that the most minute quantity taken inter- 
nally or even applied locally to an abraded skin will produce the most 
marked symptoms. The local symptoms, if taken by mouth, are a burn- 
ing sensation of the mucous membranes followed by marked congestion 
and swelling, which is sometimes so severe as to suggest that an irritant 
poison has been swallowed. The general symptoms which follow almost 
immediately include persistent vomiting, profuse diarrhea and marked 
prostration. These are often threatening and may be serious, although 
they usually last but a few hours. With these severe cases a marked 
eosinophilia is often present. Not only may there be symptoms referable 
to the gastro-intestinal tract but sometimes dyspnea which resembles an 
attack of spasmodic asthma. The above symptoms represent the more 
severe form of this susceptibility. There is a much larger number of chil- 
dren who show this sensitiveness in a milder form, often only by repeated 
attacks of vomiting after the ingestion of egg. Such a susceptibility is 
frequently lost during childhood but may persist to adult life to such a 
degree that the most minute quantity of egg taken in any form whatever 
is immediately followed by a disturbance. 

Very much less frequently similar symptoms may follow the ingestion 
of cow's milk. We have seen two infants in whom less than ten drops of 
fresh cow's milk produced symptoms of a severe form. Such a con- 
dition, however, is extremely rare, and to attribute to milk idiosyncrasy 
the common disturbances incident to artificial feeding is quite improper. 

In older children a similar sensitiveness is seen to certain cereals, 
particularly to oatmeal and buckwheat, and also to certain nuts, especially 
almonds and walnuts. In still others an extraordinary sensitiveness t( 
fruits, usually raw fruits, is seen. The most frequent example is th< 



ACIDOSIS 217 

familiar susceptibility to strawberries, less often it may be to raw apples. 
In most eases the disturbance amounts only to an attack of urticaria. 
Occasionally in the more susceptible the digestive disturbances above 
noted are also present. Similarly, but less frequently, other raw fruits, 
grape fruit, oranges and bananas, may cause symptoms. Certain shell 
fish, such as crabs, oysters, etc., may produce similar symptoms. 

From clinical observation alone many erroneous conclusions are apt 
to be drawn. The absolute proof of such sensitiveness, as has been indi- 
cated, is afforded by the cutaneous reaction which follows the application 
of the protein of any of the substances mentioned. The application of 
such tests is a matter of somewhat difficult technic and its use is only 
possible in the hands of a trained observer. 

ACIDOSIS 

For the preservation of health it is necessary that the body should 
always contain an excess of bases, in order to maintain that degree of 
alkalinity in the fluids of the body with which the various functions are 
carried on to the best advantage. This degree of alkalinity is maintained 
under normal conditions with wonderful constancy even though there is 
a continuous elaboration of acids such as sulphuric, phosphoric and car- 
bonic in the organism. The acids are neutralized and removed from the 
body by a three-fold mechanism : 

1. Carbon dioxid is given off from the lungs. 

'!. The kidneys are able to excrete an acid urine from a slightly 
alkaline blood. The alkali spared is available to neutralize more acid 
or to assist in the renewal of the alkali reserve of the body. 

3. Ammonia is formed which is capable of neutralizing acid. The 
ammonia is formed at the expense of urea, a neutral substance, and thus 
represents a clear gain of alkali for the body. 

There is a normal preponderance of alkali over acid in the fluids of 
the organism. This depends upon the maintenance of an alkaline reserve, 
very largely bicarbonates, which is found in the blood, tissue juices and 
cells of the body. So long as the eliminating mechanism for the excre- 
lion of acids is preserved the alkaline reserve is not affected, even though 
the production of acids may be greatly increased. When acids are pro- 
duced in excess or their elimination is interfered with, the normal pre- 
ponderance of bases over acids is disturbed and acidosis results. 

It is apparent that acids such as those of the acetone series may he 
formed in the body in considerable amount and yet be excreted without 
affecting the alkaline reserve. The acids are neutralized by alkalies that 
can be replaced by those of the food or by ammonia. Under such condi- 
tions there is no acidosis. When the production of acids is so great that 



218 NUTRITION 

they cannot be neutralized without diminishing the reserve of alkali, 
acidosis may be said to be present. The dividing line between the two 
conditions is a very narrow one. 

Acidosis may result from the production in excess of acids that are 
present in small amount in normal metabolism, such as aceto-acetic and 
jS oxybutyric acids. These acids are not directly poisonous but produce 
their injurious effect by depriving the body of alkali. They are present 
chiefly in diabetes and cyclic vomiting. 

Acidosis presumably may result from the failure to excrete acids 
formed only in normal amount. It is conceivable, but not yet proven, 
that acidosis may result from the abnormal loss of bases. 

The means for the detection of acidosis are chiefly those that deter- 
mine a diminution in the bicarbonate or in the total alkaline reserve of 
the blood, among which may be included the determination of the carbon 
dioxid in the alveolar air, a change in the reaction of the blood, the 
presence of acids (such as those of the acetone series) in excess in the 
blood or urine, an increased tolerance for alkalies, or an increased am- 
monia in the urine which is evidence of the attempt to neutralize an 
excess of acids. 

The methods of treatment are discussed under those diseases in which 
acidosis is found. 



CHAPTEE V 

THE DERANGEMENTS OF NUTRITION 

I n a ni t io n — M euros m us — Ma In utri t io n 

The derangements of nutrition, especially those accompanied by a 
loss of weight, form a distinct and a very large class in the ailments of 
infancy, particularly during the first year. The symptoms are often 
definite and characteristic, and for this reason have frequently been con- 
sidered and discussed as separate diseases. They are rather the result 
of several different factors and usually represent terminal stages of func- 
tional or organic disease. In adults such symptoms are usually seen 
in connection with organic disease. These cases are often very puz- 
zling, and in a large number of them a diagnosis of some constitu- 
tional disease, such as hereditary syphilis, or tuberculosis, or organic 
disease of the stomach or intestines, is erroneously made. The essential 
condition in all these cases is the inability of the infant to get from his 
food what his system needs. He can not digest or assimilate enough to 
support life. He is unable to replace from his food the daily waste of 



ACUTE INANITION 219 

his tissues. The constructive metabolism is imperfect; the process is, 
therefore, essentially one of starvation, which may be rapid or slow 
according to circumstances. 

The fault in these eases may be with the constitution of the child, 
with the organs of digestion, or, what is more generally the case, with 
the food. The problem is to adapt the food to the individual child 
under consideration. The solution is often very easy at first, but the 
difficulties multiply rapidly the longer the condition has lasted. It is 
therefore essential that the true explanation of the symptoms should be 
recognized at the earliest possible moment. Changes occur so rapidly in 
very young infants that a mistake in diagnosis and a consequent delay 
of a few days may be sufficient to determine a fatal result. The outcome 
in cases of imperfect nutrition depends almost entirely upon their man- 
agement. The condition is not one which tends to right itself. Spon- 
taneous improvement or recovery rarely takes place. Not only is careful 
observation of the child and his symptoms important but also close atten- 
tion to the body weight. A child whose nutrition is a matter of diffi- 
culty should be weighed regularly, in the early months at least twice a 
week, and once a week throughout the first year. If this is done, the first 
signs of failing nutrition are unerringly detected. If an infant does not 
gain in weight something is wrong ; a steady loss in weight is a warning 
which should never pass unheeded; for, unless the conditions are changed, 
it is practically certain to continue, and generally with increasing rapid- 
ity until the vitality has been reduced to such a point that no means 
of treatment can restore it. The younger the child the more rapid the 
loss, and the longer it has continued the greater is the danger. 

Acute Inanition. — Rapid loss of weight, frequently spoken of as acute 
inanition, is common in early infancy, when it often simulates serious 
organic disease. In older children it is not frequent, and usually is 
dependent upon some obvious cause. In all the acute diseases of the 
digestive tract many of the symptoms are due to inanition. The obscure 
cases are those in which the digestive symptoms, strictly speaking, are 
not prominent. 

The rapid loss of weight usually takes place under one of the follow- 
ing conditions: (1) When a child refuses all food, whether from the 
lucast or the bottle, or can be made to take only an insignificant amount. 
The cause of this it Is often impossible to discover. Symptoms of inani- 
tion arc sometimes seen at weaning, when a child persistently refuses to 
take food from a bottle or spoon, (2) When the food given Is entirely 
inadequate, as when an infant is nursing upon a dry breast, or one in 
which the milk supply is so scanty that the child gets practically nothing. 
It is occasionally seen later, when the breast-milk, for some unexplained 
reason, suddenly fails. (3) When the character of the food is improper. 



220 NUTRITION 

On account of extreme poverty, the infant may be getting only tea or 
toast soaked in water or albumin water. It may occur in young infants 
who are fed entirely on starchy foods. (4) When the infant at birth 
has such feeble powers of digestion, because premature or delicate, that 
he is unable to take or to digest sufficient food to maintain life. (5) 
When a sudden change of food is made to one so difficult of digestion 
that the child is unable to assimilate it. This may happen after sudden 
weaning. In such cases the symptoms of inanition are mingled with 
those of acute indigestion, but the former usually predominate. 

The mode of development depends upon the antecedent condition. 
In young infants acute inanition often follows malnutrition, when per- 
haps there has been nothing noticeable except a gradual loss in weight; 
or, if the weight has not been watched, it may be observed only that the 
infant has not been doing well. Severe symptoms may come on quite 
suddenly, and if the nature and the gravity of the condition are not 
appreciated the case may terminate fatally in two or three days. The 
loss in weight is rapid, amounting often to three or four ounces a day. 
The temperature in the newly-born may be high, but it is more often 
subnormal. The pulse is weak and may be rapid, but is at times very 
slow. The heart sounds are feeble. The urine is scanty. The extrem- 
ities are cold, and the peripheral circulation poor. There is usually com- 
plete muscular relaxation. This is especially marked in the abdomen 
where the muscles almost entirely lose their tone. The skin may be dry 
or covered with a clammy perspiration. There is extreme pallor, and 
often a peculiar bluish-gray color to the face. This is always a grave 
symptom. Cyanosis may be present in children who have previously 
cried well and in whom there is no suspicion of atelectasis. The respira- 
tions are rapid and may be irregular. There may be constant worrying 
and fretf ulness, or a condition of semi-stupor, in which the child makes 
no sign of wanting food. The fontanel is sunken and the pupils are 
contracted. The bowels usually move frequently, although there may be 
constipation, due to the small amount of food taken. When no food is 
taken for two or three days the stools may resemble meconium. 

The progress depends much upon the age of the infants. Those under 
one month usually succumb quickly. In them the symptoms sometimes 
last but a few days, seldom more than a week or two. The development 
of such symptoms in a young infant is a very serious sign. In older 
infants the progress downward is usually less- *^nid. 

The outcome of such cases is, however, always uncertain, but with 
proper treatment many may be saved. It is hard for one who is not 
familiar with the condition to appreciate the great and even the immedi- 
ate danger in which a young infant may be from inanition, notwithstand- 
ing the absence of both vomiting and diarrhea. The treatment must be 



MARASMUS 221 

immediate and energetic. Breast milk is essential. There is no oppor- 
tunity to experiment with artificial feeding. Xo food can be given if 
there is vomiting or severe diarrhea, but in the absence of these breast 
milk may be given by gavage if necessary. The intervals should be 
long — at least four hours. In the event of no vomiting but diarrhea, but- 
termilk may be given, alternating with the breast milk. If it is impossi- 
ble to obtain breast milk, buttermilk is probably the best form of diet 
unless the child is over three months of age, when feeding with protein 
milk may be attempted. Eectal feeding is of no avail. Often the symp- 
toms are largely due to a lack of water. Injections of a normal salt solu- 
tion should be given per rectum or under the skin. Hypodermoclysis is 
often of great value. Absorption is usually prompt. The rapidity with 
which shrivelled tissues will drink up water is astonishing. Normal saline 
solution should be employed in amounts from 150 to 240 c.c. once or twice 
a day. This may be repeated for several days. While the improvement 
following hypodermoclysis is frequently marked, it must be remembered 
that the effect is only temporary. Unless proper food is retained and 
absorbed or the digestion improves, the conditions are soon as bad as 
ever and subsequent injections produce less and less effect. Saline solu- 
tion may be given by the drop method into the rectum. This method is 
seldom satisfactory. Transfusion, by the direct or indirect method, may 
be life-saving. Energetic stimulation by caffein or camphor, hypoder- 
mic-ally, is indicated. Except for the stimulants, drugs are of no use 
whatever. 

Marasmus. — Gradual and progressive loss of weight, wasting, is a 
symptom of many conditions in infancy. It occurs in tuberculosis, in 
infantile syphilis, and also as a result of obvious disturbance of the gastro- 
intestinal tract. At times, however, it appears to be a vice of nutrition 
only and develops, so far as can be made out, without general or local 
organic disease. To this type the names of Marasmus, Infantile A trophy 
and Simple Wasting have been applied. 

This condition is not very often seen in the country or in private 
practice; but it is frequent in dispensary practice in all large cities, and 
i> especially common in institutions for young infants. In such institu- 
tions, fully half the deaths under one year are directly or indirectly from 
this cause. It is a very large factor in the immense infant mortality of 
large cities in summer. Although the cause of death is usually reported 
under some other na^e, the determining factor in the fatal result is the 
previous marantic condition of the patient. The primary cause may be 
a congenital weakness of constitution which may depend upon heredity. 
It is often seen in premature children. In the vast majority of cases, how- 
ever, it depends upon two factors — the food and the surroundings. 
Among the poor who live in tenements, many artificially-fed infants do 



222 NUTRITION 

very badly. This is due to neglect, to ignorance in regard to proper 
infant feeding and inability to procure what the child requires, especially 
pure cow's milk. A country infant may be neglected in many respects, 
and is often badly fed ; but he has plenty of pure air, and usually thrives. 
In the city, as long as an infant has a plentiful supply of good breast-milk 
he continues to do well in most instances, in spite of the fact that his 
surroundings are bad. When there are not only bad feeding and un- 
healthful surroundings, but also an inherited constitutional vice, we have 
all the factors required to produce marasmus in its most marked form. 
The odds are so against the infant that the feeble spark of vitality nickers 
for a few months only and gradually goes out. 

Another prominent factor in the production of marasmus is the over- 
crowding and lack of individual care of infants in institutions. Even 
though artificially fed in an intelligent manner, many infants who are 
plump and healthy on admission, lose little by little, until at the end of 
three or four months they become wasted to skeletons, dying of some 
mild acute illness, such as an attack of bronchitis, the essential cause, 
however, being marasmus. The common mistake is that of placing too 
many children in one ward with no chance of obtaining a proper amount 
of fresh air and with too little individual attention. No house-plant is 
more delicate or sensitive to its surroundings than is an infant during the 
first few months of life. 

The post-mortem findings in such cases are exceedingly unsatisfac- 
tory, and throw little if any light upon the cause of death. Every now 
and then general tuberculosis is discovered in patients dying apparently 
of marasmus, the existence of which was not previously suspected. An 
occasional lesion is fatty liver. This may lead to such enlargement of 
the organ that its weight is increased by one-half. Both to the naked eye 
and under the microscope the usual changes of fatty infiltration are pres- 
ent, often to an extreme degree. In the past too much has doubtless been 
made of this condition of the liver in marasmus. From figures given 
elsewhere (see article on Fatty Liver), it will be observed that the lesion 
is not more frequent in this condition than in infants dying from other 
diseases. Its exact relation to the condition of wasting has not yet been 
determined. 

With these exceptions the autopsies show nothing striking. In the 
stomach and intestines there is nothing of pathological importance. The 
theory advanced, that atrophy of the intestinal tubules is the explanation 
of marasmus, has found little support. 

The condition seems rather to be a failure of assimilation, owing to 
imperfect digestion, improper food, unhygienic surroundings, or feeble 
constitution. As a result, there is a progressive loss in weight, feeble 
circulation, imperfect lung expansion, lowered body temperature, and, 



MARASMUS 223 

finally, a condition incompatible with life, for resistance becomes so 
feeble that the slightest functional disturbance proves fatal. 

The general history of these cases is strikingly uniform. The follow- 
ing is the story most frequently told at the hospital : "At birth the baby 
was plump and well nourished, and continued to thrive for a month or 
six weeks while the mother was nursing him ; at the end of that period 




Fig. 18. — Marasmus; a Patient in the Babies' Hospital, Ten Months Old, Weight 
Six Pounds. Weight at birth reported to have been nine pounds. 

circumstances made weaning necessary. From that time the child ceased 
fco thrive. He began In lose weight and strength, at first slowly, then 
rapidly, in spite of the fact that every known form of infant-food was 
tried. " As a last resort the child, wasted to a skeleton, is brought to the 
hospital. 

The most constant symptom is a steady loss in weight until a condi- 
tion of extreme wasting is reached, at which point these patients may 



224 NUTRITION 

remain for many weeks. Their general appearance is characteristic. 
They have an old look ; the skin is wrinkled, has lost its tone, and hangs 
in folds upon the extremities (Fig. 18). The legs are like drumsticks; 
the abdomen is prominent; the temples are hollow; the fontanel is 
sunken ; the eyes large ; the features sharp ; and the hands resemble bird- 
claws. Often the children are reduced literally to skin and bones. 
Anemia is a very marked and almost constant symptom. Accidental heart- 
murmurs are frequently heard. The body temperature is usually sub- 
normal unless artificial heat is employed. A rectal temperature of 95° 
or 96° F. is very common, and one of 93° or 94° F. is occasionally seen. 
In addition to the pallor of the face, there may be a leaden hue. 

A not infrequent symptom is general edema. The first thing which 
calls attention to this is often an unexpected gain in weight which may 
amount to several ounces a day. The edema may increase until the 
cellular tissue of the entire body is water-logged. There are not, how- 
ever, effusions into the large serous cavities. The exact pathology of this 
nutritional edema is not clear. It is of quite frequent occurrence in cases 
of marasmus, especially in infants under six months of age. It seems 
impossible to connect it with any definite form of feeding. Thus, we 
have seen it in infants kept for a long time upon barley water, in others 
who were receiving nothing but condensed milk, in still others who were 
taking a milk formula apparently of suitable proportions. The urine in 
the marked cases shows neither albumin, nor casts, but usually an almost 
complete absence of chlorids. Coincidentally with the disappearance of 
the edema the chlorids appear in the urine, showing a close association 
between the retention of chlorids and the retention of water in the tissues. 
Thus, in one case at the height of the edema the child was eliminating 
but .008 gram of sodium chlorid daily; three days afterwards, while the 
dropsy was rapidly disappearing, the amount exceeded .5 gram. In the' 
treatment of this condition the most satisfactory food in our experience 
has been protein milk. Whether this is due to its low sodium chlorid 
content or not it is impossible to say. The administration by mouth of 
digitalis has- seemed a ls advantageous. An infant of three or four 
months can take-half a dram of the infusion three or four times daily. 

The stools are sometimes normal, but usually contain undigested food 
with mucus. No matter how carefully fed, these patients are easily upset. 
Vomiting is readily excited. The appetite in many is almost entirely 
lost; others take their food quite well and have fairly good stools but 
steadily lose weight. 

Frequent complications are thrush and bedsores which are sometimes 
seen over the sacrum or heels, but most frequently upon the occiput. 
Occasionally there is seen a reflex spasm of the muscles of the neck, pro- 
ducing a marked opisthotonus, which may last for several days or weeks. 



MARASMUS 225 

In hospital wards these infants are very susceptible to all infections, par- 
ticularly to those of the respiratory tract. Otitis, rhinopharyngitis, bron- 
chitis and pneumonia are especially common. 

The progress in most cases is steadily downward; but it may be cut 
short at any time by acute disease. Frequently these infants die suddenly 
when apparently they are as well as they have been for several weeks. In 
summer they wilt with the first days of very hot weather, and die often 
in a few hours from a slight functional derangement of the stomach and 
bowels. 

The symptoms shown by some infants that have been fed for a long 
time upon a diet almost exclusively of carbohydrates merit special con- 
sideration. They surfer from what the Germans call Mehlnahrscliaden. 
The infants may have received proprietary foods or cereal decoctions 
in order to overcome diarrhea or because milk is impossible to obtain, 
and it is a restriction to carbohydrates for a long time that causes the 
characteristic symptoms to develop. For a while they may hold their 
weight or may even gain; before long, however, they begin to lose weight 
and the loss may be extreme. There is in some instances a marked 
tendency to edema which may mask the loss. Pallor is striking. 

Of especial importance, however, are a peculiar rigidity of the mus- 
culature and a great lessening of immunity to infection. The rigidity is 
especially marked in the legs. The muscles are contracted and hard. It 
is difficult to extend the extremities. In severe cases opisthotonus may 
develop. The diminution in the resistance' to infection allows of the 
development of furuncles, otitis, bronchitis and infections of the eyes. 
Especially characteristic is keratomalacia with perforation of the cornea 
and destruction of one or both eyes. 

The condition is a severe one and is frequently fatal. The longer it 
has existed the worse the prognosis. Infants with keratomalacia seldom 
recover. The severity of the condition is in large part due not only to 
the insufficiency of the food as a whole, but to the almost complete absence 
of fat, protein and salts. It is not unlikely that vitamines are also lack- 
ing. 

With loss of weight from any cause the older the child the better the 
chances of recovery. Very young infants are always difficult subjects to 
deal with. They go down more rapidly and build up more slowly than 
those who are older. Much depends upon whether everything possible 
can be done for the child : whether a wet-nurse can be secured and whether 
the patient can have the benefit of the best surroundings, in the country 
in summer and in winter a warm climate where he can be kept out of 
doors the greater part of the time. In institutions cases in infants under 
lour months old are usually hopeless. Of those over eight months quite a 
proportion can be saved by proper treatment, even though the body-weight 



226 NUTRITION 

is reduced to eight or nine pounds. When recovery occurs it may be 
complete, and the child at two or three years may^ be as vigorous as any 
child of his age. 

The most important treatment is that which relates to prophylaxis. 
Maternal nursing should be encouraged by every possible means especially 
among the poor. For those who must be artificially fed the important 
things are a pure milk supply together with proper instruction as to how 
it is to be used in infant feeding. At the same time opportunities for 
fresh air should be secured. This is a large part of the difficulty in 
institutions. 

As far as possible, wet-nurses should be obtained if the infants are 
under four months old. For these very young patients success by artifi- 
cial feeding is generally impossible. With those of six months or over, 
intelligent artificial feeding is very frequently successful. In institutions 
we seldom succeed without at least partial breast feeding. 

For very young infants, with a temperature which is habitually sub- 
normal, some means of maintaining the body heat must be employed. 
The simplest and usually an effective means is to oil the body and envelop 
it completely in a cotton jacket and then surround it with hot-water bags 
or bottles. The room should be kept warm. In institutions it is con- 
venient to have a warm room for such infants, the temperature of which 
is kept about 80° F. These infants require no drugs but a great deal 
of careful nursing. 

Malnutrition. — Failure • to gain properly is exceedingly common 
among young children, and such cases occupy. a large part of the time and 
attention of one engaged in pediatric practice. The term malnutrition 
perhaps characterizes them better than any other. Although these chil- 
dren can not be said to be actually ill, they are very far from well, and 
their condition is often the cause of the greatest solicitude on the part of 
parents, not only from the existing state of health, but from the appre- 
hension of the development of some serious organic or constitutional dis- 
ease, especially tuberculosis. 

Certain children are delicate from birth, possessing only feeble vital- 
ity, though without giving evidence of any actual disease. They are 
often the offspring of parents of delicate constitution and poor physical 
development, or of those with tuberculosis, gout, or syphilis. Very many 
city children are included in this group. Among the poor the condition 
is the result of bad hygiene, insufficient or improper food, overcrowding, 
etc. Among the well-to-do it is seen in those who inherit a too highly 
developed nervous organization with a corresponding amount of physical 
deterioration. Another group includes those children who were prema- 
ture or very small at birth, weighing perhaps only three or four pounds. 
Many cases are traceable to improper feeding or equally poor nursing 



MALNUTRITION 227 

during the first few months. These children get a poor start in life, and 
on that account are handicapped throughout infancy. A frequent cause 
of malnutrition in infants is the pernicious custom of keeping them in 
close apartments where the thermometer ranges from 72° to 75° F., and 
where the greatest anxiety is constantly felt lest they take cold. Such 
infants may lose in weight, become anemic, and exhibit all the signs of 
malnutrition when nothing else is wrong except the conditions men- 
tioned. Malnutrition often depends upon some previous acute disease, 
especially of the stomach and intestines. 

In children who are over two years old the condition of malnutrition 
may be due to any of the factors above mentioned — inherited feebleness 
of constitution, bad feeding and its resulting indigestion, too little fresh 
air. and close confinement indoors. It is, however, at this period, much 
more frequently than in infancy, dependent upon some previous acute 
disease. As a result, an impression is left upon the child's constitution 
which lasts for months, often for years, and which manifests itself not 
by any special local symptoms, but by a general condition of debility. 
Faulty methods in education, especially overpressure in schools may have 
a deleterious effect upon the health of older children. 

Not only the weight but the general physical development is much 
below the normal. At one year the body length may be three or four 
inches less than the average. Dentition may not be materially delayed. 
Muscular development is backward; many of these children do not sit 
alone until a year old, and barely walk at two and a half or three years. 
The muscles are soft and flabby, and the ligaments so weak that paralysis 
is often suspected. The body is so small that the head seems unnaturally 
large, and a diagnosis of incipient hydrocephalus is frequently made. 
Mentally these infants are somewhat backward but the mental develop- 
ment is often strikingly in advance of the. physical. Some symptoms of 
rickets are usually present. 

The examination of the blood reveals the usual changes of a moderate 
secondary anemia. The circulation is poor, the hands and feet are fre- 
quently cold. In many children the skin is unnaturally dry; in others 
there is a disposition to excessive perspiration, particularly about the 
head. Nervous symptoms are frequently present. These children are 
restless, fretful, and irritable; they sleep badly. Enlargement of the 
lymph glands, especially those of the neck, is common. 

One of the most characteristic things about these patients is their 
feeble power of digestion and assimilation. Unremitting care and con- 
stant watchfulness are required to keep them up to even a moderate 
standard of health. The most trivial changes in food may upset them. 
Attacks of acute indigestion are usually brought on by overfeeding — the 
mistake which is almost invariably made by mothers who are discouraged 



228 NUTRITION 

with the slow progress made, and are anxious to make their children grow 
fat and strong. The balance is so delicately adjusted that the slightest 
deviation from proper rules of feeding, either as to the quality of the 
food or the quantity given, is immediately followed by an attack of acute 
indigestion, often by severe diarrhea. As a result, the child may lose as 
much in two or three days as he has gained in a month or more. These 
acute attacks, if in summer, not infrequently prove fatal. Not only do 
these patients have but little resistance to acute disturbances of the 
stomach and intestines, but any acute disease is serious — measles, whoop- 
ing-cough, and pneumonia being especially fatal. 

If under six months of age, among the poor or in institutions, such 
infants are almost certain to go on from bad to worse. In private 
practice, where it is possible to have the best care and surroundings, 
with the cooperation of an intelligent mother or nurse, a very large 
number of these infants can be reared. After the second year has passed 
the problem becomes a much simpler one, and if infectious diseases 
and other forms of acute illness can be avoided, the probabilities are 
in favor of the child's becoming stronger each year and growing to 
maturity. 

Older children are thin, pale, and undersized, particularly if the con- 
dition is constitutional or hereditary. Sometimes they are taller than 
the average for their age, and their symptoms are often attributed to 
too rapid growth. One of the most striking things about children suffer- 
ing from malnutrition is their vulnerability. They "take" everything. 
Catarrhal processes in the nose, pharynx, and bronchi are readily excited, 
and, once begun, tend to run a protracted course. There is but little 
resistance to any acute infectious disease which the child may contract. 
Often one illness quickly follows another, so that these children are not 
infrequently sick for almost an entire season. Their muscular develop- 
ment is poor; they tire readily; are able to take but little exercise, and 
their circulation is sluggish. Mentally they are usually bright, often pre- 
cocious. They are cross, fretful, and any unusual excitement produces 
an effect which lasts for some time. Their sleep is usually disturbed and 
restless; they waken frequently, and occasionally suffer from night- 
terrors. 

Digestive symptoms, if not constant, are very easily excited. Chil- 
dren of five or six years have to be fed as carefully as infants. The appe- 
tite is usually poor, and mothers are distressed because their children eat 
so little, yet, when food is urged upon them, attacks of indigestion follow 
with singular regularity. The tongue is slightly coated the greater part 
of the time. The bowels are apt to be constipated, apparently more from 
lack of muscular tone than from anything else. From time to time there 
may be large quantities of mucus in the stools for two or three days. A 



MALNUTRITION 229 

moderate amount of anemia is always present, and this ma}' be the most 
striking feature. 

The duration of the condition depends very much upon the cause. If 
the cause is constitutional or inherited, it is likely to last throughout 
childhood, but it often greatly improves about the time of puberty. When 
it follows some acute illness it commonly lasts for a few months only. 
The longer the condition has lasted and the greater the general disturb- 
ance the slower will be the improvement. The great danger is the super- 
vention of some acute disease. 

It is oftentimes difficult to find out to what the failure properly to 
develop is due. Much regarding inherited constitutional tendencies can 
be learned from the family history and from the condition of other chil- 
dren in the family. Tuberculosis must be carefully excluded. 

Other things to be considered are syphilis, rickets, diseases of the 
blood, intestinal parasites and, of course, organic diseases of the lungs, 
heart, stomach, intestines, liver and kidneys. Even malignant disease, 
though rare, should not be overlooked. It may take careful observation 
for several days, and sometimes for weeks, with repeated physical exam- 
inations, before all these conditions can be positively excluded. 

In private practice a large proportion of cases are due to improper 
feeding or nursing; next in importance are improper surroundings, and 
last come inherited constitutional conditions. In other words, most of 
these children are born healthy, but become ill or delicate in consequence 
of improper management. 

In older children, after excluding constitutional and local diseases, 
the whole life of the child must be investigated to discover the funda- 
mental condition which is at fault. A carefully obtained history from 
infancy is of the greatest assistance. It is often difficult, and sometimes 
impossible, to get at the primary factor, for in cases of long standing 
there may be symptoms connected with almost every function of the body. 
One should scrutinize closely the quality and quantity of food given, the 
amount of sleep, the hours of study and recreation, the amount of exer- 
cise in the open air, and the physical conditions surrounding the child. 
Usually the most important factor in the case can be discovered. 

The problem of nutrition is to be solved by diet and general manage- 
ment; drugs occupy a very small place in treatment. With infants when- 
ever possible breast feeding should be employed. Next in importance to 
diet is fresh air. The natural tendency of a mother who has a delicate 
infant is to house him closely and never allow him a breath of fresh air. 
It is of the greatest assistance if these children can be sent to a warm 
climate for the winter. If this is not possible, fresh air may be obtained 
by changing apartments, or by an airing in the room with the windows 
open. 



230 NUTRITION 

Cold sponging is a valuable tonic that can only be employed, however, 
with fairly vigorous infants that react promptly. If the child remains 
blue and cold for some time afterward, the cold sponging should not be 
repeated. 

Friction and massage are useful in many cases. The child should be 
laid upon the lap of the nurse, if possible, before an open fire, and should 
always be covered with a blanket. The entire body should then be rubbed 
for ten or twenty minutes with the bare hand, or, better, with cocoa 
butter. Professional operators are inclined to be too energetic for little 
children. 

The only tonics of much value are iron, preparations of malt, nux 
vomica, and cod-liver oil. Cod-liver oil is too much used in these cases, 
and in too large doses. Many of these infants can not take it at all. It 
should not be given when the tongue is coated and the appetite poor. 
The dose should always be small, e. g., ten to twenty drops of the pure oil 
three times a day, or twice as much of an emulsion. 

Experiments in treatment are nearly always unfortunate. The phy- 
sician should indicate in writing, for the guidance of the mother, specific 
rules with regard to the amount of food, the time at which it is to be 
given, the hours for bathing, sleep and airing. He should see the patient 
at regular intervals and often enough to be sure that his orders are being 
enforced. Good results are obtained only by constant watchfulness. 

The same general principles are to be applied to older children as to 
infants. The diet is of the first importance. Only the simplest and most 
easily digested articles of food should be given. Milk, beef, eggs, the 
lighter and more easily digested cereals and vegetables, bread, and fruit 
should form the diet. All sweets, pastry, highly seasoned food, candy, 
nuts, tea, and coffee should be absolutely prohibited, and, in fact, all the 
articles mentioned as "forbidden" in the Chapter on the Feeding of Older 
Children. When the appetite is poor and simple food not well taken, the 
child should not be allowed to take indigestible articles for the sake of 
eating something. Nothing should be given between meals, and regular 
hours of feeding must be followed. Three meals a day, for children over 
three years old, are better than the practice of giving more frequent feed- 
ings. Under no circumstances should children be coaxed, urged, or hired 
to eat ; much less should they be forced to do so. There is a popular mis- 
apprehension in regard to the variety in diet which children need. Most 
children do better when a very simple and fairly uniform diet is con- 
tinued. 

The nervous factor is a very large and a very important one. Many 
of these children are essentially cases of neurasthenia at as early an age 
as four or five years. Excitement and activity are what they crave and 
what must be most carefully avoided. 



SCORBUTUS 231 

The general habits of children should be directed; there should be 
regular and early hours for retiring, freedom from undue excitement, 
and interest should be awakened in outdoor amusements. Children 
should be kept as much as possible in the open air, but the amount of 
active exercise should be strictly limited. Usually they do much better 
if they can be in the country during the entire year. Only a limited 
amount of reading and study should be allowed; and if children are at 
school, care should be taken that overpressure is not the cause of the 
symptoms, particularly in an ambitious child. Cold sponging given in 
the morning, as described in the introductory Chapter on General Thera- 
peutics, is extremely beneficial to children who take cold readily. In 
general, these children require early hours, a simple diet, a quiet, regular 
life, and very little medicine. 

In recent years there has been a disposition to attribute many of the 
symptoms included in the foregoing pages to insufficiency in the secretion 
of the ductless glands. Extracts from these glands have been widely 
employed in treatment. There is no satisfactory evidence that such an 
etiology is correct or such a treatment beneficial. 



CHAPTER VI 
DISEASES DUE TO FAULTY NUTRITION 

Thi; diseases due to faulty nutrition are numerous. There ar.e two, 
however, which have been so clearly shown to originate in this way that 
they may b<3 put in a class by themselves. These are scorbutus and rickets. 
The purpose of considering them in connection with the disturbances of 
nutrition is to emphasize this relationship. 

SCORBUTUS (Scurvy) 

Scorbutus is a constitutional disease due to some prolonged error in 
diet. It is characterized by spongy, bleeding gums, swellings and ecchy- 
moses about the joints, especially the knee and ankle, hemorrhages from 
i lie nose, and occasionally from other mucous membranes, extreme hyper- 
esthesia, and often pseudo-paralysis of the lower extremities. Added to 
these local symptoms there is in advanced cases a general cachexia with 
marked anemia. While scorbutus and rickets are very frequently asso- 
ciated, they can not be considered as different forms of the same disease. 



232 NUTRITION 

Cases of scorbutus were, however, described in older writings under the 
title of Acute Eickets. 

Scurvy was well recognized and graphically described by Glisson as 
long ago as the middle of the seventeenth century. For our earliest mod- 
ern knowledge of the pathology of this disease we are indebted to the 
observations of Barlow and Cheadle. On the continent of Europe scurvy 
is most frequently known as Barlow's disease. 

Scurvy is not a rare disease. In active hospital and private practice 
many cases are seen each year. 

Etiology. — Age is an important factor; more than four-fifths of the 
cases occur between the sixth and the fifteenth months, and half of 
them between the seventh and the tenth months. -Scurvy has been seen 
in infants under a month old. The majority of the cases reported have 
been observed in private practice, often in the best surroundings. Pre- 
vious disease is not a factor of much importance. Most of the children 
attacked have been in good health up to the development of scurvy. 
In about one-fourth of the number some previous derangement of the 
digestive tract has existed. 

The only etiological factor yet known to bear any constant relation 
to the production of scurvy is diet. The important facts regarding the 
previous diet have been well brought out by an investigation of the Amer- 
ican Pediatric Society. They were as follows : 



Previous food 



Breast-milk in 12 


3ases, 
« 


alone in 10. 


Raw cow's milk " 5 


a u ^ 


Pasteurized milk " 20 


u 


" " 16. 


Condensed milk " 60 


a 


" " 32. 


Sterilized milk " 107 


a 


" u 68. 


Proprietary infant-food " 214 


u 





This table shows that while scurvy may occasionally develop with 
almost any variety of food, three stand out prominently — viz., proprie- 
tary infant foods, condensed milk, and sterilized milk. In all of these 
it would appear that something needed for normal healthy nutrition is 
wanting. Scurvy is not likely to follow unless an improper diet is con- 
tinued for a long period, usually several months. In some instances 
when it developed in nursing infants, the nurse's milk has been examined 
and found totally inadequate to the needs of nutrition, many of the chil- 
dren having exhibited serious disturbances of nutrition before any signs 
of scurvy appeared. 

Several cases have come under our observation where scurvy has 
developed in children who have been kept for four or five months upon 
raw milk, Aery greatly diluted. Scurvy may result from taking milk 
which has been pasteurized, usually when the temperature has been high 



SCORBUTUS 233 

(167° F.), and the time prolonged (30 minutes). With the v lower tem- 
perature now more generally employed (155° F.), it is less likely to 
develop. We do not believe scurvy to be a frequent result of the pasteur- 
ization of milk, and not to be weighed against the advantages of pasteur- 
ization ; but still a danger to be reckoned with. Since the general use of 
pasteurized milk the number of cases of scurvy is certainly on the in- 
crease. The number of cases which develop while on a diet of boiled or 
sterilized milk is so large that we are driven to the conclusion that the 
heating alone is the cause, especially since prompt recovery has often fol- 
lowed when no other change is made than to discontinue the heating. 
These facts show that the sterilization of milk is attended with some 
disadvantages, and should not be continued as the sole diet for long 
periods. 

The addition of carbohydrates to the food affords no protection, but 
rather increases the danger of scurvy. 

Scurvy frequently develops after the prolonged use of condensed milk 
or proprietary foods as the sole diet. 

There is certainly a predisposition to this disease on the part of some 
infants, for with the same diet one child may develop the disease while 
another remains free. We have seen twins fed in exactly the same way, 
one of whom developed scurvy while the other did not. 

While it may be regarded as established that the cause of scurvy is die- 
tetic, no single dietetic error can be held responsible for the disease. It 
has been recently shown that there are substances in foods vitally neces- 
sary for health, the vitamins. It is quite clear that scurvy depends 
upon the absence of some of these. Either they are lacking in the food 
or have been destroyed by prolonged heating. Typical scurvy can be 
produced in some animals by giving a diet chiefly of grain with no 
fresh vegetables or fruit. The addition of these latter articles immedi- 
ately cures the disease. So it is with children who are at once relieved 
by orange or lemon juice, or as Freise has shown, by the dried alcoholic 
extracts of vegetables. 

Lesions. — The most marked effects of scurvy are seen in the bones, 
blood-vessels, and the blood. The number of recorded autopsies in this 
disease is not large. We have had the opportunity of making examina- 
tions in seven cases. The findings are remarkably uniform, but repre- 
sent, of course, the extreme results of the disease. The most striking 
lesion is subperiosteal hemorrhage, which is practically constant and may 
occur almost anywhere in the body, but affects chiefly the bones of the 
lower extremities; it is often very extensive, and may reach from the 
knee to the great trochanter, or from the ankle nearly to the knee. 
Extravasations may also be found between the muscles, and blood may 
infiltrate the cellular tissue in the neighborhood of the joints. Besides 



234 NUTRITION 

these lesions resulting from hemorrhagic periostitis the bone itself may 
be affected. Separation of the epiphysis from the shaft of some of the 
long bones, generally at the shoulder, lower end of the femur or lower 
end of the tibia, is found in most of the fatal cases. Notwithstanding 
the serious lesions near the large joints, the joints themselves are usually 
normal. 

The microscopical changes in the bones due to scurvy are quite char- 
acteristic. They consist in hemorrhages within the marrow as well as 
beneath the periosteum. There is a diminution of osteoblastic activity; 
the osteoblasts are relatively few in number and the formation of new 
bone is decreased or has altogether ceased. What bone has been formed, 
however, is well calcified. The absorption of bone is not increased. For 
this reason the shaft of the bone is firm but there is a place of least 
resistance in the subepiphyseal zone owing to the lack of bone formation. 
It is through this weakened zone that separation occurs as the result of 
very slight traumatism. 

The marrow undergoes extensive changes. The marrow cells in areas, 
especially in the neighborhood of the epiphyses, have largely disappeared, 
leaving only the supporting cells. In addition there are almost always 
found some of the changes characteristic of rickets. 

The visceral lesions are inconstant. Those most frequently found are 
small hemorrhages beneath the pleura, pericardium, and peritoneum, 
sometimes into the various organs, also bronchopneumonia and nephritis, 
which occasionally occur as complications. 

There may be small extravasations found upon the surface of any of 
the mucous membranes. Alterations in the blood-vessels are undoubted lv 
an important factor in bringing about the disposition to hemorrhage. 
The changes in the blood, in the' gums, and the lesions of the skin will be 
considered with the symptoms. 

Symptoms. — In many cases a period of indisposition, fretfulness, 
pallor, and failing nutrition precedes the local symptoms, but usually 
tenderness of the legs is the first symptom noticed. In the beginning 
this is occasional and so slight as to cause the infant to cry only upon 
being handled. Later it becomes almost constant and is very acute. At 
first this soreness is not very definitely localized, but is generally more 
marked about the knees and ankles. Some swelling may be noticed, often 
just above the ankle joints. Coincident with these may be seen the 
changes in the mouth. The gums are of a deep purplish color, swollen, 
particularly about the upper central incisors, and may quite cover the 
teeth. They bleed from the slightest irritation, and sometimes spon- 
taneously. The child now becomes fretful and cross, sleeps badly, loses 
color, weight, and appetite. He may become quite cachectic in appear- 
ance. All Ihese symptoms come on very gradually, often with periods of 



SCORBUTUS 



235 



a few days in which apparent improvement is seen. Sometimes they may 
continue for several weeks without making any perceptible impression 
upon the child's previously good condition. 

If the disease is recognized, and proper treatment instituted, rapid 
improvement follows, with complete and permanent recovery. If not 
recognized, and the faulty diet is continued, the disease advances to the 
more severe form. The tenderness of the legs becomes exquisite, so that 
any movement or even the slightest touch causes the child to scream with 
pain or apprehension. The posture is very characteristic. There is 
semiflexion of thighs and legs and outward rotation at the hip. (See Fig. 




Fig. 19. — Scurvy Showing Characteristic Swellings and Posture. Patient 8^ 
months old, fed exclusively upon malted milk after the age of 3 months. Epiphyseal 
separation at the upper extremity of both humeri, lower extremity of both femora and 
lower extremity of left tibia. Prompt and complete recovery. 



19.) In this position the child often lies motionless and voluntary mo ve- 
il tents of the extremities can not be excited. Paralysis is often suspected. 
Hie disability is chiefly owing to the extreme pain which motion pro- 
vokes, but may depend upon epiphyseal separation. Small ecchymoses 
are frequently seen about any of the large joints, resembling the ordinary 
"black-and-blue" spots, and these often confirm the opinion previously 
formed that the child has met with some accident. The swelling near 
the joints, particularly the knee, may be so great that the limb is nearly 
twice the size of its fellow. The buccal symptoms are usually striking. 
Id addition to spongy, swollen, bleeding gums, dark purplish bags may 
be seen over teeth not yet through. There may be bleeding from the 
roof of the mouth or from the pharynx. The pain is sometimes so severe 
;is seriously to interfere with taking food ; there is moderate though rarely 
extreme salivation. "Blood may be vomited or passed with the feces or 
the urine. In the severe cases the stools are rarely normal, more or less 
catarrhal colitis usually being present. The general condition is one of 
grave anemia, accompanied by a marked cachexia and progressive wast- 
ing. The child cries almost constantly, sleeps little, and is truly a pit- 



236 NUTRITION 

iable object. Slight fever is usually present; and in some of the more 
rapidly progressing cases with extensive lesions a temperature of 102° or 
103° F. is common. Unless recognized and the cause removed, the con- 
dition grows steadily worse, the symptoms continuing until death occurs 
either by slow asthenia, or suddenly from heart failure, or from some 
intercurrent disease, such as bronchopneumonia or acute gastro-enteritis. 
The duration of the illness in the fatal cases is from two to four months. 

The onset is gradual in the great majority of the cases, the earliest 
symptoms noticed in the order of frequency being pain and tenderness 
of the legs, soreness and sponginess of the gums, disability, anemia, 
cutaneous hemorrhages, and very rarely hematuria. 

Pain and tenderness are very prominent, being noted in about 95 per 
cent of the cases; in the majority they are present only on motion or 
handling. The location of the pain and tenderness in 184 cases was as 
follows : Lower extremities alone, 133 ; upper extremities alone, 2; lower 
and upper, 42 ; lower and trunk, 7. In all but two cases, therefore, the 
lower extremities were affected, the lower part of the thigh and the leg 
just above the ankle being the usual seat. 

Disability, or pseudo-paralysis, is a very common symptom, and in all 
severe cases a constant one. It exists in varying degrees from a slight 
disinclination to use the limb to complete helplessness. In many cases 
it is more marked than the pain, and has led to a diagnosis of polio- 
myelitis. 

Swellings are associated with pain and tenderness in most of the 
severe cases. They are most marked near the joints, but may extend 
for some distance along the shafts of the bones. In nearly all cases the 
location is the lower part of the thigh or the lower part of the leg, and 
usually of both sides. Swellings are occasionally seen at the shoulders or 
wrists ; in rare cases there may be swelling about the elbows or hips or 
over the ribs, scapula, or ilium. Eedness is not generally present, but the 
parts may have a dark purplish color. It is to the hemorrhages that both 
the swellings and the discoloration are chiefly due. There is often marked 
edema of the affected limbs. 

Protrusion of the eyeball is present in a small proportion of the 
cases; an extreme exophthalmus is sometimes seen, and is due to orbital 
hemorrhage. 

The gums are affected in nearly all cases, the exceptions being those 
recognized and treated early. Hemorrhage occurs in about one-half the 
cases, and frequently there is ulceration not unlike that of a mercurial 
stomatitis. It is rather curious that, though the lower teeth are cut first, 
the upper gum is almost always most affected, and in the milder cases 
usually alone involved. Of 45 cases in which no teeth had been cut, the 
gums were affected in 24 and normal in 21. This is sufficient to disprove 



SCORBUTUS 237 

the old opinion that the gums are affected only when teeth have appeared. 
The severe inflammation and ulceration sometimes seen seem to be the 
result of secondary infection. 

Hemorrhages beneath the skin are present in about half the cases. 
They are rarely extensive, usually multiple, and their location is no 
doubt often determined by a slight traumatism. Hemorrhages from the 
mucous membranes are not quite so frequent. There may be bleeding 
from the gums, nose, bowels, and rarely from the stomach. Hemorrhages 
in most cases are frequently repeated, but seldom profuse. 

Epiphyseal separation is seen in most of the very severe cases. It is 
most frequently either of the lower epiphysis of the femur or the tibia, or 
the upper epiphysis of the humerus, and is often bilateral. The actual 
separation may be caused by some slight injury, the condition of the bone 
predisposing to this occurrence. In several cases of our own with sep- 
aration which recovered, rapid union occurred under anti-scorbutic treat- 
ment. 

Early in the disease, even though marked swelling of the limbs may 
be present, an X-ray examination may show little or nothing. The sub- 
periosteal hemorrhages can not usually be made out until there is a deposi- 
tion in the effusion of the salts of calcium. Then they appear with great 
clearness as spindle-shaped thickenings of the bones, sometimes running 
the whole length of the diaphyses. These are absorbed very slowly and 
require weeks or months to disappear. Changes at the epiphyses are 
also found. They consist in distortions and irregularities of the normal 
line. Separation of the epiphysis can be occasionally made out. Some 
rachitic changes also can usually be recognized. 

Anemia is slight in the early stage, but increases as the disease 
progresses. Blood examinations may show marked reduction of the 
hemoglobin, sometimes to thirty-five or forty per cent; also in nearly 
all cases a proportionate reduction of the red cells. The changes are 
those of an ordinary secondary anemia. 

The urine contains albumin in about one-fourth of the cases; in 
nearly half of those containing albumin casts also are found. In rare 
cases hematuria is an early symptom. Blood cells usually in moderate 
numbers are found in practically all but the mildest cases, and are of 
some diagnostic importance. 

Evidences of general malnutrition are present in all advanced cases, 
varying, of course, greatly in degree. In a few infants under our own 
observation the weight, color, and general appearance of health have 
continued in spite of very decided local symptoms. In most of them the 
impaired nutrition is shown by loss of appetite, occasional attacks of 
vomiting, and still more frequently by derangements of the bowels, 
which vary from slight indigestion to a serious catarrhal condition of 



238 NUTRITION 

both small and large intestine. It is with the latter that the discharge 
of blood is usually seen. 

Association with Rickets. — In the American Pediatric Society's in- 
vestigation great pains were taken to obtain definite and accurate data 
regarding this. Of the cases, 340 in number, in which this point was 
noted, symptoms of rickets were present in 152, or 45 per cent. Mild 
grades of rickets are, of course, impossible for us to recognize. Post 
mortem, rickets is almost invariably found associated with scurvy, for 
the reason that during the age at which scurvy may develop rickets is, 
in hospital patients, a well nigh universal disease. There is no reason 
for believing rickets and scurvy to be different forms of the same dis- 
ease. The two most striking characteristics of scurvy, viz., tendency 
to hemorrhages and prompt curability by fresh food and fruit juices, 
have no counterpart in rickets. 

Diagnosis. — The disease with which infantile scurvy is most fre- 
quently confounded is rheumatism. In fully four-fifths of the cases 
which have come to our notice this has been the previous diagnosis. The 
extreme rarity of rheumatism under one year should always make one 
cautious; pain and tenderness of the legs only, should, in an infant, 
invariably suggest scurvy rather than rheumatism. The extreme disabil- 
ity has often led to a diagnosis of poliomyelitis, but here again the acute 
tenderness should set one right. Many cases of scurvy come into the 
hands of the orthopedic surgeon with a diagnosis of joint or spinal dis- 
ease. Where the swelling was mainly of one limb we have twice known 
a diagnosis of malignant disease to be made, from the cachexia, the 
shape of the swelling, the discoloration, and the pain. We have known 
two cases to be operated upon by eminent surgeons, once with a diag- 
nosis of sarcoma and once of ostitis of both tibiae. Not until the sub- 
periosteal hemorrhages and epiphyseal separation were discovered was 
the nature of the trouble suspected. 

The diagnosis of scurvy seldom presents any difficulties to one who 
has once seen a case. No one need err if the essential features of the 
disease are kept in mind: the extreme soreness of the legs, spongy, 
swollen gums, swelling near the large joints, a tendency to hemorrhages, 
and usually a history of the prolonged use of some proprietary infant 
food, or sterilized or condensed milk. The epiphysitis of hereditary 
syphilis has many symptoms in common with scurvy, but it usually 
occurs at an earlier age (before the fifth month) and other evidences of 
syphilis are usually present. If any doubt exists, this will be removed 
by the prompt improvement and generally rapid cure folloAving an anti- 
scorbutic diet. 

Prognosis; — This is invariably good if the disease is recognized early. 
No patients with symptoms so serious improve with such marvelous 



SCORBUTUS 230 

rapidity as do the great majority of those with scurvy, under proper 
management. The figures of the American Pediatric Society's report on 
this point are interesting. The average duration of the disease before 
treatment was begun in over three hundred cases was somewhat over 
three weeks. In eighty per cent striking improvement was noticed dur- 
ing the first week of treatment, and in forty per cent within three days. 
Over two-thirds of these cases were well within three weeks, and nearly 
one-third within one week, after the beginning of treatment. 

It is only when the disease is of long standing, when the malnutrition 
is severe, or when serious complications, usually involving the digestive 
tract, are present that the symptoms persist and the issue becomes doubt- 
ful. It is difficult to tell what the exact mortality of scurvy is. Any case 
allowed to go on may result fatally. The younger the infant the more 
likely is this to occur. We have seen five fatal cases. In one of our 
patients death resulted from hemorrhage which followed an incision into 
an epiphyseal swelling at the lower end of the femur, made before the 
patient was seen and which persisted despite all treatment. Barlow's 
early article included thirty-one cases with seven deaths. It is rare that 
scurvy leaves any permanent effects. EecOvery is not only rapid but 
complete. Eelapses are extremely rare and have been observed only in 
one or two cases, where chronic indigestion existed of so extreme a 
character that proper feeding was impossible. The after-effects are 
usually the result of prolonged malnutrition, of which the attack of 
scurvy was only one manifestation. 

Treatment. — Prevention requires that all infants reared on sterilized 
or pasteurized milk should be given other food much earlier than was 
formerly thought necessary. It is not enough to add gruel or farinaceous 
foods. Fruit juices should be begun as early as the fifth or sixth month. 
Beginning with two teaspoonfuls the amount may gradually be increased 
to two or three tablespoonfuls daily and continued as a regular part of 
the diet. The early use of broth in which green vegetables have been 
cooked is also of value, or the grated vegetable may be given to the infant 
as a puree. The treatment of scurvy is usually very simple — viz., to dis- 
continue all proprietary foods, condensed milk or sterilized milk, and to 
substitute a diet of fresh cow's milk, modified to suit the child's digestion. 
With this change alone improvement will soon begin and gradual recov- 
ery take place. However, when fresh fruit juice is added improvement 
is much more rapid. It should always be combined with the change 
in diet. Orange juice is to be preferred, but the juice of any fresh ripe 
fruit will answer the purpose. Oranges should be sweet and fresh. From 
two to four ounces of the juice a day are required, best given in divided 
doses, about one hour before the milk-feeding. It may he given plain 
Of diluted with water. In some cases when not well tolerated by the 



240 NUTRITION 

stomach, it is better given at night when no food is taken. Potato 
also has marked anti-scorbntic properties, and may be given in the 
form of a puree to infants as young as eight or ten months. The only 
really difficult cases to manage are those in which the general condition 
approaches one of marasmus, or when scurvy is accompanied by marked 
gastric or intestinal disturbance. When an intestinal catarrh is present, 
with the bowels moving five or six times a day, one may hesitate to give 
the fruit juice for fear of increasing these symptoms. In a number of 
instances we have seen intestinal symptoms, which had resisted ordinary 
measures, immediately improved by the fruit juice, thus establishing 
their intimate connection with the scorbutic condition. 

Other things of value are fresh beef juice, and for older children all 
fresh vegetables, especially potato. The anemia and malnutrition call 
for iron, cod-liver oil, and other tonics, which should be given after active 
symptoms of the disease have disappeared. Infants with scurvy should 
be handled as little as possible, and should be particularly protected 
against exposure in their extremely susceptible condition. To relieve 
pain and prevent deformity the affected limbs should be immobilized by 
splints during the period of marked symptoms if epiphyseal separation 
has taken place, and in many other severe cases. 



RICKETS (Rachitis) 

Rickets is a chronic disease of nutrition. While the only important 
anatomical changes are found in the bones, it is not to be regarded as a 
disease of bone, but as a very complex pathological process, the result of 
disturbed metabolism, which affects chiefly the bones, but also the mus- 
cles, ligaments, mucous membranes, and nearly all the organs of the body, 
including the nervous system. It occurs especially between the ages of 
six and eighteen months. While not a fatal disease per se, rickets adds 
very greatly to the danger from all acute diseases in infancy, and even 
to some degree also to those of later life. 

The great frequency of rickets has only recently been recognized. It 
is probably, at least in cities, the disease from which infants most fre- 
quently suffer. It has been possible to determine this only since the 
pathology has been firmly established, for many cases give no clinical 
evidence and the disease can be recognized only post mortem. The symp- 
toms by which we recognize rickets are chiefly due to bone changes, and 
these must be quite well marked before they are discovered clinically. 
For this reason rickets may run its course without any suspicion having 
been aroused as to its presence. Schmorl found in 386 consecutive 
autopsies upon children dying oetween the second month and the fourth 



RICKETS 241 

year, evidence of rickets in 90 per cent, while 9G.6 per cent of infants 
between the fourth and eighth month were rachitic. There can be no 
doubt that among the poor in cities, rickets is an almost universal disease. 

Etiology. — Certain facts in the causation of rickets are well known. 
It is closely related to improper feeding and bad hygienic surroundings. 
Artificially-fed children are much more prone to the disease, especially 
those who are badly fed. Breast feeding does not entirely protect against 
the disease, though it greatly modifies its character. Severe forms of 
rickets are not common in nursing children unless lactation is unduly 
prolonged, as, for example, when nursing is continued for fifteen to 
eighteen months without other food. There is a predisposition on the 
part of certain children to acquire rickets quite independent of the food. 
Of two children that are nursing the same woman, one may develop 
rickets perhaps in a severe form and the other may escape it; and 
allowing a rachitic infant who has been breast fed to nurse a woman 
whose own child is not rachitic, brings no assurance that the rickets will 
be cured. 

The diet of children who develop rickets upon artificial feeding is 
most frequently deficient in fat and often at the same time in protein, 
while it is apt to contain an excess of carbohydrates. It has been believed 
that the most important factor is the deficiency of fat. Eickets is exceed- 
ingly common in children reared upon the proprietary foods, nearly all 
of which are very low in fat and contain an excess of carbohydrates. It 
is also common in children who are reared upon sweetened condensed 
milk. 

According to Feer, infants in the mountainous parts of Switzer- 
land seldom develop rickets although they may have been breast-fed 
for only a short time and thereafter are given a diet almost exclu- 
sively of carbohydrates. It is doubtful if diet has the importance that 
has been ascribed to it in the past. 

Though animals under domestication suffer from rickets, it is impos- 
sible to produce the disease by even the most abnormal diet. Certain 
experiments have been made which show that a condition of the bones 
resembling rickets may be produced in animals by a diet deficient in 
calcium salts, and furthermore that this may be cured simply by the 
addition of these salts to the food. The conclusion can not, however, be 
drawn that rickets in children is produced in this manner. In the first 
place the bony condition in the artificial disease is not histologically the 
-a me as that seen in rickets; again, rickets in the child is not cured 
simply by the administration of calcium salts; and, finally, rickets 
develops when these elements have not been deficient in the food. 

Rickets is essentially a disease of cities, being most often seen in 
children living in crowded tenements where, in addition to improper 



242 NUTRITION 

food, the hygienic surroundings are the poorest. For this reason poor 
ventilation, filth and lack of sunlight have been regarded as potent fac- 
tors in producing the disease. Their exact influence is difficult to deter- 
mine. 

Distribution of Rickets. — It was formerly held that rickets was almost 
unknown in many parts of the world. It is now apparent that prac- 
tically no region escapes. The greatest frequency of the disease, however, 
is in the temperate zone. Tropical and semi-tropical countries are rela- 
tively free from rickets. But the inhabitants of these countries, partic- 
ularly the negro and the Italian, when removed to cities of the temperate 
zone, suffer most frequently and severely. In the cities of America no 
race is exempt from the disease. In New York the greatest susceptibility 
is among the negroes and Italians. The extreme cases of rickets seen are 
almost invariably in one of these nationalities. It is exceptional to see in 
a dispensary or hospital a child of either of these races who does not 
show, to a greater or less degree, the signs of rickets. These two southern 
races seem to bear very badly the climate and the confined life of the 
northern cities. So far as our observations are concerned, there is no 
peculiarity in the food of these people which explains the prevalence of 
rickets among them, and it must be attributed to a race peculiarity. In 
the country, the immunity from rickets may be partly due to the more 
prevalent custom of maternal nursing, and partly to the better surround- 
ings, the increased resistance of the children rendering them much less 
susceptible to unwholesome influences than children in the cities. 
Among dispensary and hospital patients of our large cities rickets is 
exceedingly common, and is seen chiefly in the foreign elements of the 
population. 

Season. — This apparently has an important influence upon the devel- 
opment of the disease. The figures from four large outpatient clinics 
show that from January to June there were treated more than twice as 
many rachitic patients as from July to December. Schmorl has reported 
that he found early cases at autopsy rather more commonly in the cold 
months than in the warm, that the most active cases were considerablv 
more frequent in the cold months, and that the vast majority of cases 
with evidences of healing were seen in the summer and early fall. The 
active symptoms of rickets are more frequently seen and are more severe 
in the winter and spring. What it is that determines this we are as 
yet quite unable to say. 

Heredity. — The influence of heredity is difficult to determine. It is 
believed by some excellent authorities to be a factor in the production 
of the disease. Siegert has reported numerous instances where children 
with rachitic parents developed rickets while other children of non- 
rachitic parents living in the same environment and receiving the same 



RICKETS 243 

food did not develop rickets. Elgood has given the history of a woman 
who was married three times. By her first and third husbands, who had 
not had rickets, she bore children who remained free from the disease, 
while by her second husband, who had suffered from rickets, she bore 
five children, all of whom developed rickets. There seems to be no 
greater reason for denying the influence of heredity in rickets than 
there is in arteriosclerosis or tuberculosis. 

Previous Disease. — Eickets not infrequently develops in syphilitic 
children; the connection, however, seems to be no closer than with any 
other cachexia. Chronic disorders of the digestive tract sometimes pre- 
cede and often follow the development of rickets. It appears to develop 
quite independently of previous disease. 

Eickets affects both sexes with equal frequency. The symptoms 
usually manifest themselves between the sixth and eighteenth months. 
Congenital and late rickets will be considered separately. 

Experimental Rickets. — Eickets is never found in wild animals; in 
those under domestication, especially with in-breeding, it is by no means 
unusual. In zoological gardens it is quite prevalent. It would appear 
easy, therefore, to produce rickets, but the attempts have been almost 
always unsuccessful. By depriving animals of calcium and phosphorus 
severe lesions of the bones have been produced, enlarged epiphyses, bend- 
ing of the bones and even fractures, but the condition is an osteoporosis 
and not rickets. 

By bacterial inoculation Morpurgo produced true rickets in white 
rats. Findlay restricted the activity of puppies and saw rickets develop. 
Klose and Matti claim that true rickets results in dogs from early 
thymus extirpation. It is undoubtedly true that rickets did follow some 
of their operations, but that it was due to the removal of the thymus 
seems open to question. 

Pathology. — Eickets is a disorder of nutrition, the result of some 
disturbance of metabolism in which calcium plays a very important role. 
The exact nature of this disturbance is not yet understood. Three theories 
have been advanced in explanation of the deficiency of calcium in the 
bones, which is the most striking characteristic of the disease. The first 
one, that rickets is due to a lack of calcium in the food, is not supported 
either by clinical or experimental evidence. The second theory is that 
the disease is due to an increased excretion of calcium as a result of 
disturbances of digestion. It is very likely that the increased excre- 
tion of calcium occurs only in rachitic children. Diet alone or dis- 
turbed chemical processes are not sufficient to account for it. The third 
theory advanced is that although sufficient calcium is furnished in the 
Food, it is excreted in excess because the bones are incapable of absorbing 
it. This is the theory that has the most clinical and experimental evi- 



"V 



-J 



244 NUTRITION 

deuce in its favor; though what produces the incapacity of the bone to 
retain calcium is quite unknown. 

Lesions.. — The only constant and characteristic lesions of rickets are 
found in the bones ; these changes are sufficiently definite to give it a 
place as an essential disease. One of the most striking features of 
rachitic bones is their unnatural flexibility. This is due to the lack of 
mineral salts in the bones and especially to the lack of calcium. Nor- 
mally bone contains about one-third organic and two-thirds inorganic 
matter. In marked rickets the proportions are reversed, the bones often 
containing twice as much organic as inorganic matter. While all the 
inorganic elements are. actually diminished the phosphorus and mag- 
nesium may be relatively increased. The chief loss is in the calcium. 

The changes in the shafts and flat bones are universal. Those at the 
epiphyses show a marked parallelism with the activity of growth. Where 
growth is most rapid the lesions are most advanced. The middle ribs are 
earliest and chiefly affected,, then the other ribs and the lower femoral 
epiphyses, the lower extremities of the radius and tibia, and eventually 
in some cases all the long bones, including the metacarpal and the 
phalanges. There are characteristic changes in form. The most com 
stant is enlargement at the epiphyses, which is most strikingly seen at 
the lower extremities of the radius and tibia and at the costochondral 
junction of the middle ribs. All the sharp angles, borders and prom- 
inences of the bones are effaced. The curvatures of rachitic bones are 
allowed by the increased flexibility due to the loss of mineral salts. They 
may be due to a variety of causes. Some are simply an exaggeration of 
the . normal curves much increased by the swelling of the epiphyses; 
others are due to muscular action, to atmospheric pressure, to some 
unnatural posture, such as the cross-legged position, to the weight of the 
limbs or the weight of the body. Marked deformity is usually due' to 
displacement of the epiphysis or to fracture. Displacement of the epi- 
physes is rare except in the ribs, where it occurs to a certain extent in 
every. advanced case. Fractures of the long bones are very common. 
The bones most frequently broken are the radius and ulna; next in order 
the ribs,. humerus, femur, fibula and clavicle. The fractures are usually 
of the green-stick variety with more or less impaction and are generally 
followed by the production of considerable callus, though subperiosteal 
solution of continuity is occasionally found with no deformity and little 
if any callus. When bending occurs there is a. production of new tissue 
beneath the periosteum to compensate for the mechanical disadvantage 
of position in which the new bone is placed. • The shafts are frequently 
greatly thickened.. The principal change in the form of the flat bones 
consists in the production of large bosses or prominences upon the 
parietal and frontal bones, due to an increase of vascular, immature 



PLATE II 



- 




RICKETS 24.5 

bone beneath the periosteum. Bosses are found where the norma' 
bending produces the greatest stress upon the bone. The deficiency in 
calcium over areas in the occipital bone that are thin even under normal 
conditions, allows them to indent under the finger. This is craniotabes. 

In a longitudinal section of one of the long bones the principal 
change seen at the extremity is that the cartilaginous layer which unites 
the epiphysis and the shaft is very much enlarged both in width and 
thickness, the latter being sometimes four or five times the normal. The 
transitional zone is a whitish or bluish-white color, rather softer than 
normal cartilage. On one side it blends with the cartilage of the epiphy- 
sis, on the other it presents an irregular clentated border. The nor- 
mal red marrow may cease a quarter or half an inch from the epiphysis, 
its place being taken by a light gray or whitish layer that microscopically 
is seen to be fibrous tissue. The replacement of so much marrow is 
perhaps the reason for some of the anemia that is prominent in severe 
rickets. The epiphyseal centers of ossification are but slightly affected. 

In the process of healing the epiphyseal swellings slowly diminish in 
size and may quite disappear; the slight curvatures may be entirely over- 
come and the greater ones much lessened. Some of the long bones remain 
more or less permanently thickened and with a denser and thicker cor- 
tical layer. The beading of the ribs becomes almost imperceptible; the 
bosses upon the skull shrink very markedly and may leave scarcely a 
trace of their existence. In most cases except in Italians and negroes the 
active process in rickets comes to an end by the time the child is two and 
a half years old, often at two years. 

Microscopical Appearances. — When normal conditions obtain at the 
epiphyses, the cartilaginous intercellular substance between the lowest of 
the four layers of cartilage cells becomes infiltrated with calcium, form- 
ing rigid columns. These direct the vessels budding up from the marrow 
against the cartilage cells which are then destroyed by erosion. The col- 
umns themselves are partly consumed by osteoblasts but the remains of 
them act as the centers around which bone is formed by osteoblastic activ- 
ity. The new bone is first formed as osteoid tissue, which differs from 
mature bone only in its containing no calcium. When it absorbs calcium 
it becomes true bone. It absorbs calcium so soon after its formation that 
only a narrow layer of osteoid tissue is ever found in health. Marrow 
cells accompany the capillary loops. The cartilage itself is nourished by 
vessels that spring from the perichondrium and run transversely in the 
so-called cartilage canals. Throughout the whole skeleton all the bone is 
well calcified with the exception of the narrow zone of osteoid tissue. 

In rickets the mosl striking feature is the prcscm-c of large amounts 
of timeless bone, or osteoid, throughout the whole skeleton. It is more 
marked in some situations than others but it is a universal process. At 



246 NUTRITION 

the epiphyses the calcium is also absent from the intercellular ground 
substance. The marrow vessels are not directed against the cells but 
they grow in all directions, breaking up the normal contour of the epi- 
physeal line. Some of the cartilage grows down undisturbed, or islands 
of cartilage cells are formed and not destroyed. The cartilage is not 
formed in excess. It is found in excess because it is allowed to remain. 
The transitional zone, or ''metaphysis," is weakened and nature attempts 
to remedy this by the production of fibrous tissue and osteoid tissue. In 
this way the metaphysis is increased greatly in diameter and also in 
thickness; for, on account of its inelasticity, it expands laterally as the 
result of muscular action or weight and does not return to its former 
position. Vascularization of the metaphysis is accomplished by a per- 
sistence of the cartilage canals. 

When healing takes place the osteoid tissue in the flat bones and the 
shafts of the long bones absorbs calcium, and the transformation into 
normal bone is rapidly completed. At the epiphysis the first step is the 
deposition of calcium in the cartilage on the epiphyseal side of the last 
cartilage canals persisting in the metaphysis. Vessels from these bud 
back and destroy the cartilage. The metaphysis is thus protected from 
a further production of cartilage. That which remains is gradually dis- 
integrated and normal bone takes the place of the osteoid tissue and 
connective tissue. There is no anatomical explanation of the deficient 
growth which is occasionally encountered. It must result from perma- 
nent damage to the function of the proliferating zone of cartilage cells. 

Healing is not always a continuous process. Eelapses of the disease 
occur. As proof of this lines of calcification may be found buried in the 
rachitic zone. Two and occasionally three of these are encountered. 
They represent abortive attempts at healing. 

Visceral Lesions. — These are not infrequent, but are not essential to 
rickets. In the lungs they are due to deformities of the chest wall and 
to complications. Beneath the deep lateral furrows which are so com- 
mon, there is found a part of the lung in a state of more or less complete 
collapse. This is accompanied by emphysema of the portion just ante- 
rior to it. Acute and chronic bronchitis and bronchopneumonia are 
exceedingly frequent. A low grade of chronic catarrhal inflammation 
of the stomach and intestines is common, and is often associated with 
dilatation of these organs. The spleen is enlarged in most cases during 
the period of active symptoms. This is usually moderate in degree. 
The swelling of the spleen is chiefly due to simple hyperplasia. Enlarge- 
ment of the liver is less frequent, and may occur with or without that of 
the spleen. There are no constant changes in the structure of these 
organs. The lymph nodes are frequently enlarged. This is due to 
simple hyperplasia, and has no close connection with rickets. Cerebral 



RICKETS 



247 



changes are rare, and those described are rather of accidental occurrence, 
than dependent upon the rachitic process. As stated under Symptoms, 
enlargement of the head is usually due to thickening of the cranial bones. 
Although hydrocephalus is occasionally seem it is extremely doubtful 
whether it is more frequent than in patients not rachitic. Hypertrophy 
of the brain lias been described in connection with rickets, but as yet 
this does not seem to be established by sufficient pathological evidence. 
The muscles are flabby from imperfect nutrition, and sometimes atrophied 




Fig. 20. — Costochondral Junction in Marked Rickets. (A) cartilage, (B) rib, (C) 
masses of cartilage cells, (D) metaphysis or transitional zone, composed of masses of 
cartilage cells, osteoid tissue, blood vessels and fibrous tissue. Normal marrow in 
this zone is absent. — Note that the epiphyseal line no longer exists. 



from disuse, but no essential anatomical changes have been demonstrated 
in them. 

Symptoms. — The symptoms upon which a diagnosis of rickets can be 
based are chiefly bony symptoms. Lesions of the bones must exist souk 1 
weeks before they reach a degree that can be recognized clinically. 
Schmorl has found microscopical evidences of rickets as early as the 
end of the second month. In the clinic we seldom see unmistakable 
rickets before the fourth or fifth month. A well-marked case of tickets 
makes a striking picture (Plate III)., and one nol easily mistaken. 



248 NUTRITION 

There are seen the large head, beaded ribs, narrow chest, prominent abdo- 
men, symmetrical swellings of the epiphyses of the wrists and ankles, 
and curvatures of the extremities. The beginning of symptoms is nearly 
always insidious, and the patient does not usually come under observation 
until they have existed for several weeks, often several months. 

Early Symptoms. — The most constant early symptoms are sweating 
of the head, extreme restlessness at night, constipation, beading of the 
ribs, and craniotabes. The head-sweating is rarely absent, and may con- 
tinue for several months. It is especially profuse during sleep, the per- 
spiration standing out in large drops upon the forehead, often being 
sufficient to wet the pillow. This is one of the causes of the nasal and 
bronchial catarrhs so common in rachitic infants. There is marked rest- 
lessness during sleep: the children tossing about their cribs, kicking off 
the clothes, and never having the quiet, natural slumber of healthy in- 
fants. This may be due to many causes, but when persistent and asso- 
ciated with marked perspiration of the head, rickets should be suspected. 
In many rachitic infants serious nervous symptoms may be seen due to 
associated tetany, such as laryngismus stridulus, and general convulsions. 
Constipation is frequently seen as an early symptom, although it is more 
marked in the later stages of the disease. 

The beading of the ribs is almost invariably the first appreciable 
change in the bones, and it is well-nigh constant. This forms the so- 
called "rachitic rosary," consisting of nodules at the line of junction of 
the costal cartilages and the ribs. It may be slight, or there may be a 
row of knobs as large as small marbles. In many cases with marked 
thoracic deformity, little or no beading of the ribs is seen externally, 
although at autopsy it is found to be very marked upon the internal 
surface of the chest. The costochondral junctions of newly-born infants, 
especially the more vigorous ones, are readily palpable. Care should be 
taken not to confound these with the rachitic rosary which appears only 
after several months. In infants under six months there may be found 
soft spots in the cranium, usually over the occipital or posterior portions 
of the parietal bones. These are from one-fourth to one inch in diam- 
eter, and there are usually several of them present. By pressure with the 
linger they give a sort of parchment-crackling sensation. This condition 
is known as craniotabes. Craniotabes is a rachitic manifestation and 
depends in no wise upon syphilis. A rachitic cachexia is not usually 
present until the symptoms have existed for several months, and in many 
cases it is not seen at all. 

Deformities. — The deformities of rickets are almost invariably sym- 
metrical in character, and usually numerous. In extreme cases almost 
every bone in the body is affected. 

Head. — This usually appears to be too large, and although it may not 



PLATE III 




Typical Rickets 

Showing the large head, narrow chest, prominent abdomen, marked enlargement 
of the epiphyses at the wrists and ankles. There are also curvatures of the forearms and 
legs which are not so well shown. 

The patient a child two and a half years old. 



RICKETS 249 

be greater in circumference than that of a healthy child of the same age, 
it is out of proportion to the rest of the body. In marked cases the 
increase in circumference may be one or two inches. The enlargement is 
chiefly due to thickening of the cranial bones. In one case with marked 
deformity, we found the skull over the parietal bones half an inch in 
thickness (Fig. 21). This thickening diminishes with recover)', but in 
most cases the head remains throughout life larger than it should be. 




Fig. 21. — Rachitic Skull. From colored child two years old, horizontal section, inner 
surface; showing thickening of the bones, especially the frontal, and open fontanel. 

Tbe shape of the rachitic head is somewhat square (Fig. 22), owing to 
the formation of large bosses over the parietal and frontal eminences. 
It is flattened at the occiput from pressure, and flattened also at the 
vertex. In extreme cases, the prominences upon the frontal and parietal 
bones may be so great as to produce quite a marked furrow along the line 
of the sagittal and frontal sutures, and one at right angles to this along 
the coronal suture (Fig. 23). This condition gives unusual prominence 
lo the forehead. Marked deformity of the Head lias Been observed in 
about one-third of our cases. The sutures may remain open for an 



250 



NUTRITION 



unnatural time, occasionally until the end of the first year. The fontanel 
is late in closing, being frequently found open at two and a half, and 

sometimes even at three years. 
Often at eighteen or twenty 
months the fontanel is two 
inches in diameter. The veins 
of the scalp are often promi- 
nent, and the hair is frequently 
worn from the occiput, owing to 
restlessness during sleep. Oc- 
casionally rickets and hydro- 
cephalus are associated, but the 
association is accidental. 

Chest. — Beading of the ribs 
has already been mentioned. 
This is the most characteristic 
feature, but in the majority of 
cases there are, in addition, 
lateral depressions over the 
lower third of the chest, at the 
line of junction of the carti- 
lages with the ribs, with ever- 
sion of the lower border of the 
ribs. In severe cases these depressions or furrows are so great as 




Fig. 22. — Rachitic Head. Italian child two 
years old; square, prominent forehead and 
flat vertex. 




Fig. 23. — Rachitic Skull from a Child One Year Old. 

bosses and wide fontanel. 



Showing frontal and parietal 



RICKETS 



251 



to cause serious deformity (Plate IV). Usually there is a great 
(liminutiou iu the transverse, and an increase in the anteroposterior, 
diameter of the chest. Fig. 24 shows the outline of the chest of a rachitic 
child of two years, compared with that of a healthy child of the same age. 
Another frequent deformity is the "rachitic girdle/' which consists in a 
transverse depression ahout two inches broad, extending from one side of 
the chest to the other, a short distance above its lower border. The chest 
wall yields at the attachment of the diaphragm which becomes more 
nearly horizontal. As a result of this the liver becomes somewhat dis- 
placed downward. Marked thoracic deformity was seen in about twenty 
per cent of our cases, but in only a small proportion was the chest nor- 
mal. 

The factors in the production of the thoracic deformity are the con- 






A b 

Fig. 24. — A, Horizontal Section of a Rachitic Chest, child two years old, showing 
lateral furrows: B, Section of Chest of Healthy Child of the Same Age. 



traction of the diaphragm, atmospheric pressure, and soft chest walls, 
these yielding at the point where they have least resistance, viz., at the 
junction of the costal cartilages and the ribs. The swelling of the costo- 
chondral junction, which is much accentuated by the displacement of the 
cartilages on the ribs, limits to a marked degree the capacity of the 
thorax. When there exists any obstruction to the entrance of air, as with 
bronchitis, hypertrophied tonsils, or adenoid growths of the pharynx, the 
thoracic deformities are exaggerated. Irregular chest deformities depend 
upon the co-existence of pathological conditions in the lungs. Pigeon- 
breast is occasionally seen, but it is doubtful if this depends upon rickets 
alone. 

Spine. — In very man}' of the milder cases this is normal. The most 
characteristic deformity consists in a posterior curve (kyphosis), which 
is a general one, usually extending from the mid-dorsal to the sacral 
region (Fig. 25). This existed in nearly half of our cases. In the 
early part of the disease it disappears entirely on suspending the 



252 



NUTRITION 



child, or making extension upon the extremities; hut in cases of long 
standing it may not disappear entirely by these tests. Very much less 
frequently there is seen a rotary curvature. This, in our experience, has 
been more frequently with- the convexity to the left side than- to the 
right — the opposite of the common form of lateral curvature seen in 
young girls. Marked lateral curvature in children under three years is 
usually rachitic. 

The clavicle is affected only in severe cases. The usual deformity 
consists in an exaggeration of the anterior curve at the inner third of 

the bone, which is somewhat shortened and 
its extremities enlarged. It is not infre- 
quently the seat of green-stick fracture. 

Deformities of the pelvis belong to ob- 
stetrics rather than to pediatrics. The most 
common rachitic change is a diminution of 
the anteroposterior diameter and a narrow- 
ing of the subpubic arch. 

Extremities. — Deformities of the upper 
extremities are usually symmetrical. The 
humerus; is affected only in severe cases. It 
has a forward and outward curve, although 
rarely a very marked one. Both the epiphy- 
ses are enlarged, although the upper one can 
not well be made out unless the child is very 
thin. The radius and ulna are frequently 
aifected. They present a convexity upon 
their extensor surfaces, which in some cases is very marked, partic- 
ularly in children who have been creeping. Green-stick fractures 
are quite frequent here as they are also in the femora. They are fre- 
quently multiple and occur from very slight, causes, sometimes appar- 
ently from muscular contraction. Multiple fractures may be found with 
no separation, the„ periosteum apparently still remaining intact. They 
are frequently found 'in the fibula. Eachitic changes at the epiphyses 
are more common than in the shaft, enlargement of the epiphyses, at the 
wrist being' one of the most constant bony deformities of rickets (Plate 
III). Less. frequently similar swellings are seen at the elbow. Enlarge- 
ment of the ends of the "metacarpal bones or the phalanges we have seen 
but seldom and only in extreme cases. 

The lower extremities are rather more frequently affected than the 
upper, but' in a similar way. The femur _is involved only in severe 
cases; it commonly presents a general forward and outward curve, 
which is mainly due to the weight of the legs as the child sits. Occa- 
sionally there is also an outward rotation of the femur, when children 




Fig 



25. — Rachitic Curva- 
ture of the Spine. 



PLATE IV 





Deformity of the Chest in Severe Rickets 
In the upper picture, giving the external view, is shown a deep oblique furrow at the 

junction of the ribs and costal cartilages, these meeting at an acute angle. 

In the lower picture the ribs have been separated from the spine and spread open, 

showing the same deformity as it appears from within, looking forwards. 
From a colored child ten months old. 



RICKETS 



253 



have been allowed to sit much in a cross-legged posture. When such 
children begin to walk, the toes are turned very far outward. The 
principal deformities of the lower extremity are bow-legs and knock- 
knees. Knock-knees are more common in females, and are believed to 
be due to an overgrowth of the inner condyle of the femur. Enlarge- 
ment of both condyles can be demonstrated in most of the marked cases 
of rickets. The cases of slight bow-legs may be due simply to swelling 
of the epiphyses, the shaft of the bone being quite normal. This point 
we have verified by post-mortem observations. Such are probably most 
of the deformities which disappear spontaneously. The most severe 
cases of bow-legs are often associated with some degree of antero- 
posterior curvature, and the latter may be the principal deformity. 





Fig. 26. — Multiple Fractures in Rickets. Showing both arms of the same patient; 
fractures also of both femora. 



Enlargement of the epiphyses at the ankles is usually present when it is 
seen at the wrists, and nearly to the same degree. Enlargement of 
the upper epiphyses of the tibia and the fibula is seen only in severe 
cases. The cause of the deformities of the leg is not, primarily, at least, 
walking too early, since they are common in children who have never 
walked; slight deformities, however, may be aggravated by early walk- 
ing. A change which has not been sufficiently emphasized is the arrested 
growth of the long bones ; this is one of the most characteristic features 
of rickets. A rachitic child of three years often measures in height four 
or five inches less than a healthy child of the same age, the difference 
being almost entirely in the lower extremities. 

All the ligaments, but particularly those about the large joints, are 

lax and frequently elongated. This may lead to the deformity known as 

weak ankles, or to an over-extension at the knee (genu recurvatum) ; 

also to unnatural mobility at the hips, shoulders, elbows, or wrists. 'The 

10 



254 NUTEITION 

condition of the ligaments plays an important part in the production of 
spinal deformities. 

Muscles. — The muscular symptoms of rickets are almost as constant 
and as characteristic as those of the bones. The muscles are small, very 
flabby, and poorly developed; hence rachitic children are unable to sit 
erect, or to stand or walk at the usual age. Of one hundred and fifty- 
one cases in which the elate of walking alone was investigated, only 
twenty-seven, or eighteen per cent, walked before the fifteenth month; 
forty-seven per cent were not walking at the eighteenth month; twenty 
per cent, not at two years ; and ten per cent, not at two and a half years. 
Late walking is one of the most common symptoms for which advice 
is sought by parents with rachitic children. The muscular power in the 
extremities is sometimes so feeble as to suggest paralysis. We have seen 
a number of cases in which the symptoms so resembled paralysis, that 
even expert diagnosticians were unable to differentiate rickets from pol- 
iomyelitis except by the electrical reactions, those in rickets being usually 
normal or exaggerated. In other cases the symptoms may suggest 
cerebral palsy of the flaccid type. The muscular symptoms may be 
marked when the bony changes are slight, and conversely. As no lesions 
of the muscles have been demonstrated, the symptoms are probably due 
to imperfect nutrition. Two other symptoms depend chiefly upon the 
condition of the muscles, viz., pot-belly and constipation. 

Pot-belly is quite an early symptom, and in most cases a very marked 
one (Plate III). It was noted in sixty per cent of our cases. The en- 
largement of the abdomen is uniform. It is everywhere tympanitic, and 
it may be as tense as a drumhead. It is due to a loss of tone in the 
abdominal muscles, and in the muscular walls of the stomach and in- 
testine. It is aggravated by chronic indigestion and excessive intestinal 
fermentation. The enlargement is thus mainly from tympanites. There 
may be a marked degree of dilatation both of the stomach and the colon. 
To a very small degree only, does the large abdomen depend upon swell- 
ing of the liver or spleen. 

The constipation of rickets, as already suggested, depends upon the 
loss of tone in the muscular walls of the intestines. It may alternate 
with diarrhea. It rarely happens that a rachitic child has habitually 
normal evacuations from the bowels. Hard, dry, constipated stools fre- 
quently set up a condition of chronic catarrh of the colon in which large 
masses of mucus are discharged. 

Fever. — According to some observers there is a febrile movement 
which belongs to the active stage of rickets, but we have never been able 
to satisfy ourselves of the truth of this observation. 

Dentition. — As a rule, dentition is late and apt to be difficult, i. e., 
it is associated with attacks of indigestion or other disturbances which 



EICKETS 255 

may be serious. Individual cases, however, present great variation in 
regard to this symptom. A study of the progress of dentition in one 
hundred and fifty rachitic children gave the following results : in fifty 
per cent the first teeth were cut on or before the eighth month; twenty 
per cent of the cases had no teeth at twelve months, and in eight per 
cent none had appeared at fifteen months. Even though the first teeth 
come at the usual time, the progress of dentition is usually retarded by 
the development of rickets. The character of the teeth in rickets is 
usually good. This is in striking contrast to hereditary syphilis, where 
the tendency to early decay is constantly seen. 

General Appearance. — Children suffering from marked rickets 
are almost always anemic. The majority are fat and flabby. The tissues 
are soft and have but little resistance. Earely, they may be thin, like 
patients suffering from marasmus. 

Rachitic patients are very prone to suffer from hypertrophied tonsils, 
adenoid growths of the pharynx, and enlargements of the lymph nodes 
of the neck. In all forms of acute illness the feeble resistance of these 
patients is very evident. This is especially true in acute disease of the 
lungs. 

The mucous membranes are very vulnerable in all rachitic patients. 
From the slightest indiscretion in diet an attack of acute indigestion or 
diarrhea may be brought on, and from a very insignificant exposure, 
catarrhal inflammation of the upper or lower air passages is excited. 
I n rachitic patients all such attacks are prone to run a protracted course. 
Inflammation of the trachea and larger bronchi is likely to extend to the 
smaller bronchi and the lungs. 

The downward displacement of the liver and spleen from contraction 
of the chest should not be mistaken for enlargement of these organs. 
Moderate enlargement of the spleen is very common during the stage 
of most active symptoms, i. e., from the sixth to the twelfth month. 
Great enlargement of either liver or spleen is infrequent. 

Blood. — Anemia is present in most of the marked cases, its intensity 
varying with the severity of the rachitic process. The blood picture is 
usually that of an ordinary secondary anemia. Leucocytosis is often 
present; it is more marked in cases accompanied by an enlarged spleen. 

Nervous Symptoms. — These are among the most frequent mani- 
festations of rickets. Restlessness at night has already been men- 
tioned as a prominent early symptom. Pain and tenderness are rare. 
A disposition to muscular spasm is seen in many cases. There may 
be laryngismus stridulus, general convulsions or other manifestations 
of tetany. It was formerly believed that rickets was the cause of the 
convulsions. It seems now apparent that it is the associated tetany 
which is intimately dependent upon rickets. The clinical evidences 



256 NUTRITION 

of rickets may be very slight yet the nervous symptoms be very marked. 

Calcium Metabolism. — Owing to the remissions and relapses that 
occur in rickets and the impossibility of determining whether the 
disease is active or not, it has been a difficult matter to study the 
calcium metabolism of rickets. The experiments of Schabad show 
plainly that in early cases either the retention of calcium is very low 
or there is an actual loss. In older cases there may still be a diminished 
retention or it may be nearly normal, depending upon the stage of the 
disease. In convalescence the retention is two or three times the normal. 

Course and Termination. — Rickets is essentially a chronic disease, and 
its course is measured by months. The active symptoms in most cases 
continue from three to fifteen months, being interrupted from time to 
time by remissions, but these are seldom appreciated clinically. 

The earliest symptoms of improvement are a diminution in the 
nervous symptoms, especially in the restlessness at night; increased 
muscular power, as shown by a disposition to stand or walk; diminution 
in the head-sweats; disappearance of the craniotabes; and improve- 
ment in the anemia. The changes in the deformities are very slow, and 
from month to month almost imperceptible. When improvement once 
begins, however, it usually goes steadily forward. 

Congenital Rickets. — In the middle of the last century, all bone 
abnormalities apparent at birth were believed to be due to fetal rickets. 
Further investigation has shown that most of them were examples of 
chondrodystrophy or osteogenesis imperfecta. Kassowitz and more 
recently others have maintained that rickets is usually, if not always, 
congenital in origin. More careful clinical observation and especially 
pathological studies have shown, however, that evidences of rickets are 
not to be found at birth. There is probably no such condition as fetal 
rickets, 

Late Rickets. — Rare instances have been reported of bony deformi- 
ties in all respects like those of rickets, developing in children from 
six to twelve years old. The course is slow and the deformity fre- 
quently extreme. A number of cases studied microscopically by such 
authorities as Schmorl and Schmidt leave no room for doubt as to the 
existence of the condition. It is very unusual in this country. We have 
never seen a case. 

Acute Rickets. — Although from time to time cases have been reported 
with this title, from a study of the histories it is clear that the great 
majority, if not all of them, were cases of infantile scurvy. It is doubt- 
ful whether, strictly speaking, there is such a thing as acute rickets. 

Diagnosis. — The diagnosis of rickets is not usually difficult. The 
most important early symptoms for diagnosis are sweating of the head, 
craniotabes, great restlessness at night, delayed dentition, and enlarged 



RICKETS 257 

fontanel. Each of these, taken separately, may mean something else, but 
collectively they can mean nothing but rickets. In the later stages some 
of the characteristic deformities are usually present; the most constant 
are beading of the ribs, enlargement of the epiphyses of the wrists and 
ankles, and bow-legs. 

Special symptoms, when unusually prominent, may give rise to diffi- 
culty in diagnosis. The enlargement of the head may be mistaken for 
hydrocephalus. The delayed dentition and large fontanel of the cretin 
may be mistaken for rickets. Muscular weakness may be so great, espe- 
cially when affecting the legs, as to make it easy to mistake a rachitic 
pseudo-paralysis for actual paralysis due to a cerebral or spinal lesion. 
When walking is much delayed, rickets may be passed over as simple 
backwardness. In nearly all of the last-mentioned group of cases the 
diagnosis may be established by a careful search for the bony changes, 
and by the fact that in rickets there is only a general weakness of all 
the muscles, and not actual paralysis of any limb or group of muscles. 
The greatest difficulty is usually found when the muscular symptoms 
are marked and the bony changes slight, as is not infrequently the case. 
Here the question is, whether rickets is sufficient to explain all the symp- 
toms, or whether in addition some other condition is present. The 
electrical reactions will usually decide the question of poliomyelitis, while 
the presence of cerebral symptoms, exaggerated knee-jerks, and rigidity 
of the legs, will usually mark infantile cerebral paralysis. The bony 
enlargements of syphilis may be confounded with those of rickets. The 
bony changes of early syphilis, although affecting the epiphyses are 
seen at an earlier age and are generally accompanied by pain and ten- 
derness, sometimes by epiphyseal separation, none of which are seen in 
rickets. The bony changes of late syphilis affect the shaft rather than 
the extremities of the long bones; when the bone is enlarged near the 
joint it is usually upon one side only. In syphilis there may be necrosis, 
while in rickets breaking down of bone is never seen. From scurvy, 
rickets is differentiated by the absence of marked hyperesthesia, ecchy- 
moses, and other hemorrhages, the changes in the gums, and most of all 
by the fact that anti-scorbutic diet produces no immediate change in 
the symptoms. The diagnosis of rachitic curvature of the spine from 
vertebral caries will be considered in connection with the latter disease. 

Prognosis. — Rickets per se is seldom, if ever, a cause of death. It is, 
however, a large factor in the mortality of the first two years, as it 
predisposes strongly to many forms of acute disease. It is an important 
etiological factor in certain serious nervous conditions, especially tetany. 
Rickets adds very greatly to the danger from all acute diseases of 
infancy, particularly those of the respiratory tract. The encroach- 
ment upon the capacity of the lungs by a marked thoracic deformity, 



258 NUTRITION 

may in itself be enough to keep a child in a delicate condition and 
retard its growth. At the same time such a condition is a constant 
invitation to acute attacks of bronchitis or pneumonia. The effect of 
rickets upon the future health of the child depends chiefly upon the 
presence and extent of the thoracic deformity. When this is severe, 
the child usually succumbs to some acute respiratory disease during 
the first few years of life. When this is absent, although children 
may remain somewhat dwarfed on account of their short legs, in other 
respects they may be as well as if they had never been the subjects 
of rickets. 

Treatment. — In considering the treatment of rickets, the natural 
course of the disease is to be kept in mind, viz., that active symptoms 
frequently continue only until the end of the first year, rarely longer 
than the eighteenth or twentieth month. The most important period 
for treatment, therefore, and the one in which it is most effective, is 
from the sixth to the eighteenth month. The earlier the treatment 
is begun the better will be its results. General treatment after the 
eighteenth month, has very little effect upon the disease, for by this 
time most of the harm has been done. The course of the disease when 
untreated is toward spontaneous recovery. Most of the cases seen in 
private practice are of a mild type and recover without special treat- 
ment, often no diagnosis being made until later in life, when the bony 
deformities or stunted growth indicate the previous existence of rickets. 

Diet. — The most frequent dietetic error in rachitic patients being an 
excess of carbohydrates and an insufficient supply of fat, it follows 
that condensed milk, proprietary infant foods, and large amounts of 
farinaceous foods of every description should be stopped. A suitably 
modified cow's milk should be substituted or for young infants a 
wet-nurse should be secured. But supplementary feeding of cow's 
milk should be given so as to insure a sufficient supply of calcium. As 
soon as possible other food, such as thick gruels, scraped meat, fruit 
juices or stewed fruit, should be offered and vegetable soups from which 
the vegetables have been strained out or in which they are very finely 
divided. Most infants are eight to ten months old before rachitic symp- 
toms are observed; to them the above mentioned articles of diet may 
be given almost immediately unless digestive symptoms are marked. 
Breast feeding should be interrupted. Cream is often badly borne and 
some other form of fat must be substituted. The fat of crisp bacon 
upon stale bread or zwieback serves well. The change to solid food 
should be made earlier than with normal children, and not more than 
a pint of milk should be allowed a day. 

Hygiene. — In large cities it is almost impossible to secure for rachitic 
patients the surroundings they require. Whenever possible, such chil- 






EICKETS 259 

clren should be sent to the country ; but when this is out of the question, 
much may be accomplished by frequent excursions upon the water or 
into the country, by keeping children as much as possible in the parks 
and open squares of the city, and securing plenty of fresh air in sleep- 
ing rooms. Cold sponge-baths given every morning, do much to lessen 
their susceptibility to rhinopharyngitis and bronchitis. Sunshine, 
though difficult to obtain in large cities, is a most efficient therapeutic 
agent. The establishment of suburban hospitals and homes for these 
cases would do much to lessen the mortality from rickets. 

Medicinal treatment. — In a disease which tends so uniformly to 
recovery when causal conditions are removed, it is difficult to estimate, 
by clinical observation, the real value of medicinal treatment. Arsenic 
and iron are valuable in the treatment of rickets, the special indication 
for their use being the presence of marked anemia. Profuse sweating 
may be relieved by small doses of atropin, i. e., gr. 1/800, three or four 
times a day, to a child of six months. The special remedies most used 
are cod-liver oil, phosphorus, and preparations of calcium. 

Various preparations of calcium have long been employed with the 
belief that they could supply lime to the tissues. It is now practically 
certain that calcium is present in sufficient quantity in the blood. It 
cannot be utilized. Calcium, therefore, in active rickets has no value. In 
convalescence, during the stage of extreme calcium retention, it may 
be of assistance. It may be offered in the form of acetate or lactate. 
The two important remedies for rickets are cod-liver oil and phosphorus. 
Xo remedy for rickets has held its place so long as has cod-liver oil. 
Phosphorus, popularized in the treatment of this disease by Kassowitz, 
has also some value ; its most striking results are seen in the early cases 
and when nervous symptoms are marked. The best results are obtained 
by a combination of these two remedies. The officinal oil of phosphorus 
is used in combination with cod-liver oil, gr. 1/300 to 1/200 is given 
three times a day with one-half dram to one dram of the oil. Striking 
confirmation of the clinical observations regarding the value of this 
combination is furnished by the metabolism experiments of Schabad who 
found the percentage of calcium retention greatly increased by the use 
of cod-liver oil and phosphorus. 

Treatment of the Rachitic Deformities. — The deformities of the 
chest are less amenable to treatment than are most of the others. After 
the third year something can be done by gymnastics to develop the chest 
muscles and to increase the pulmonary expansion. 

The deformity of the spine (kyphosis) may usually be overcome by 
postural treatment. The patient should lie upon a hard bed; no pillow 
should be allowed under the head, but in severe cases one should be 
placed beneath the back, so that the head and buttocks are slightly lower 



260 NUTRITION 

than the lumbar spine. While sitting, the shoulders should be kept 
back and the trunk supported. For a few minutes each day the child 
should be placed upon the face, and the deformity overcome by raising 
the buttocks while pressure is made upon the spine. In severe cases, 
an apparatus for giving spinal support, either by a steel brace or a plaster- 
of -Paris jacket, may be worn a few hours each day when the child is 
sitting up. Other means should be employed, especially friction and 
massage, to develop the spinal muscles. 

In very many cases slight deformities of the extremities are outgrown 
when the general treatment can be properly carried out. If the deform- 
ity is not great and not increasing, it is safe to continue with general 
treatment only. If the deformity is marked or if it increases in spite 
of the constitutional treatment, orthopedic apparatus should be applied. 
Something may be done toward straightening the bones by intelligent 
manipulation. Walking should be discouraged until the bones are quite 
firm. Friction of the extremities and massage will do very much to in- 
crease muscular development. The habit of sitting cross-legged — a very 
common one in rachitic children — should be prevented, and in fact any 
other habitual posture, on account of the danger of increasing certain 
deformities. But little is to be expected from the use of apparatus for 
the correction of rachitic deformities after the child is two and a half 
years old; since at this time, and often even at two years, the bones are 
so firm that no amount of pressure from a steel brace will have any effect. 

Without going fully into the question of the surgical treatment of 
rachitic deformities, for which the reader is referred to text-books of 
general and orthopedic surgery, we will only state that osteotomy seems 
to us to offer decided advantages over the other means of treating severe 
deformities. The best results from osteotomy are obtained when the 
operation is delayed until the fourth or fifth year, by which time the 
bones are sufficiently firm and solid. Operations in the second year are 
generally unsatisfactory, and those in the third year often so, because of 
the bending of the bones which takes place subsequently. The deform- 
ities which require operation are bow-legs and knock-knees, less fre- 
quently the curvatures of the femur or the bones of the forearm. 



CHAPTER VII 

DIATHESES 

The conception of constitutional differences is not a new one. It has 
been recognized for more than a hundred years that, under the same 
conditions, one person reacts physically in a different way from another, 



THE EXUDATIVE DIATHESIS 261 

and that this is especially true of infants. To explain this, a peculiarity 
of constitution has been assumed. Before the development of bacteri- 
ology this idea was generally accepted to explain such a condition as 
scrofula. When it became apparent that many of the symptoms of 
scrofula were, in reality, symptoms of tuberculosis, the conception was 
gradually given up. But in the last few years emphasis has again 
been laid upon variation in constitution and this has come into more 
and more prominence. It should be recognized, however, that the basis 
of a division into groups rests upon clinical symptoms only, and for 
this reason there have been great differences of opinion in regard to 
the limits of the various diatheses and what infants should be included 
in one or the other group. While many diatheses have been described, 
there are but two that stand out with sufficient clearness to justify their 
consideration as entities. These are the "exudative diathesis" of Czerny 
and the "neuropathic" or "psychoneuropathic diathesis." 



THE EXUDATIVE DIATHESIS 

This diathesis has been described under different names by many 
observers. It is the one which was first recognized. Many of the symp- 
toms were formerly classed under the old name of "scrofulous" dia- 
thesis. But the symptoms which are now considered by Czerny to 
belong to the exudative diathesis depend in no way upon tuberculosis. 
They are manifested early in life and are largely confined to lesions of 
the skin and mucous membranes. Infants with this diathesis often 
show early seborrhea of the scalp, and they are particularly liable to 
eczema, which may develop upon the face alone or all over the body. 
They are usually well nourished, oftentimes very fat infants, but their 
musculature is usually flabby and there is almost always anemia of 
greater or less intensity. Depending upon the extent of the eczema, 
eosinophilia is present. Less commonly, in this country at least, the 
papules and lesions of lichen strophulus are formed. There is a marked 
tendency to rhinopharyngitis and as a result there is frequently otitis 
media. The superficial glands, especially those in the neighborhood 
of the lesions, are somewhat enlarged. 

The general nutrition, as has been said, is usually fairly main- 
tained, but when the eczema is severe the irritation from this and the 
consequent loss of sleep may seriously affect the infant's general con- 
dition. 

Though chemical changes have been described in these children, 
there are none sufficiently striking to justify a diagnosis without clinical 
symptoms. There is a tendency to retention of chlorids, and an increased 



262 NUTRITION 

sugar content of the blood has been claimed, but both of these are 
inconstant. 

After the first year the manifestations of the exudative diathesis 
usually diminish in intensity; they are frequently absent after the sec- 
ond or third year, though they may remain in evidence for a longer 
period. There can be no doubt that giving a large amount of food 
increases the severity of the symptoms and that such children do better 
upon a restricted diet. Fat in excess in the diet increases the severity 
of the cutaneous symptoms and a diet of milk alone, after the first few 
months, aggravates the condition. It is wise to employ carbohydrates 
as early as possible. For this reason thick gruels should be used as 
diluents, even in the first few weeks, and the milk replaced by them as 
far as this can be done. By the eighth or ninth month, or even earlier, 
cereal may be given with a spoon once or twice a day. Thereafter, milk 
should form only a small part of the diet and throughout infancy and 
childhood the quantity of food should be regulated and restricted more 
particularly than with other children. 



THE NEUROPATHIC DIATHESIS 

The neuropathic child may give evidences of his peculiar constitution 
during infancy, or sometimes not until he is several years of age. No 
matter at what age the symptoms are manifest, it is usually inheritance 
that is responsible for the highly irritable nervous system of these chil- 
dren. In almost all instances one or both parents are neurotic. Environ- 
ment plays distinctly a secondary part, but is important even in infancy. 

The Neuropathic Infant. — The condition may reveal itself even in 
the first weeks of life in an unusually early reaction to sights and sounds. 
Infants may fix their attention upon people and objects as early as the 
third or fourth week, and thus are readily startled and terrified by 
things to which the normal infant pays no attention. Sleep is often- 
times disturbed. Such children are precocious and on this account 
often receive much attention from parents and nurses, which practice 
has a tendency greatly to increase their symptoms. Ordinarily, how- 
ever, not much notice would be given to the abnormal constitution except 
for the development of two symptoms which are particularly striking. 
The first of these is vomiting and the second, diarrhea. 

The vomiting is usually characterized by the fact that it takes place 
very readily without any apparent discomfort and that the simplest 
forms of food and even water may be vomited. Vomiting may develop 
without sufficient cause and the usual symptoms ordinarily associated 
with it are entirely absent. Frequently the food is simply regurgi- 



/ 

THE NEUROPATHIC DIATHESIS 263 

tated into the mouth where it may be held and swallowed again or it 
may run out at the corners of the mouth. 

The vomiting may be only occasional with no interference with weight 
and growth, or it may be so severe as to cause a marked loss of weight 
and even threaten life. It sometimes ceases spontaneously; at other 
times it may be most obstinate. The diarrhea also varies in severity. It 
may occur with breast-fed as well as artificially-fed infants. The stools 
may be only slightly more frequent than normal, three to five a day, 
and well digested; or they may be much more numerous and passed 
through the intestinal tract so rapidly that they are undigested and 
frequently contain mucus. 

The diarrhea is apparently caused by an excessive irritability of 
the intestines, an increased reaction of the nerves to the stimuli which 
ordinarily produce moderate peristalsis. As a result, the food is hur- 
ried along more or less unchanged, together with increased intestinal 
secretions. The diarrhea may be most obstinate. Marked and even 
serious malnutrition may result. 

A recognition of the essential condition is necessary for proper 
treatment. Such infants should be kept as quiet as possible with no 
excitement or unnecessary handling. If vomiting is present, the food 
should be given at four-hour intervals. When, in spite of reduction of 
the fat and elimination of sugar, vomiting continues, solid food given 
with a spoon is usually retained. This food is preferably some form 
of cereal such as farina or barley thoroughly cooked, but so thick that 
it must be given with a spoon. Infants as young as four or five months 
take this admirably, — two or more ounces every four hours. The propor- 
tion of one part of cereal to ten parts of milk is usually thick enough; at 
limes, however, it must be as thick as one part of the cereal to five of 
milk, in order to prevent regurgitation. If a flour is used, this should 
be cooked for at least an hour, — for coarse cereals three to four hours 
are necessary. This diet may be continued until other food is added 
at the end of the first year. Water should be given between the feedings. 

The treatment of the diarrhea is conducted along the same lines 
as with diarrhea from other causes. The essential condition, an in- 
creased peristalsis, is the same in either case. The irritation of the 
intestinal contents should be diminished. The irritating products, the 
lower fatty acids, are found in smaller amount when there is an excess 
of protein in the diet and when the fats and sugars are much reduced. 
For this reason with nursing infants striking benefit is often seen after 
substituting buttermilk for one or more feedings of breast milk. With 
artificially fed children a reduction of the sugar is usually necessary. 
Carbohydrates in the form of gruels are much better borne than the 
sugars. When diarrhea is excessive, protein milk may be necessary, at 



264 NUTRITION 

first without and later with the addition of a preparation of maltose. 
Success is only obtained with continuous and intelligent care. 

The Neuropathic Child. — He is the product of both hereditary condi- 
tions and the environment in which he lives. The child who is nervous 
by inheritance is rendered much more so by continual association with 
nervous parents, especially if, being an only child, he is the subject 
of their undivided solicitude. Acquired nervousness is by no means 
infrequent as the result of disease or bad environment, but is lost as 
soon as the influence that is responsible for it is removed. Nervousness 
is more common in girls than in boys and is especially seen in the Hebrew 
and Latin races. It is much increased by a faulty method of living, by 
late hours and especially by tea and coffee and, in boys, by cigarette 
smoking. 

The symptoms relate not only to the nervous system but to the physi- 
cal condition of the child as well. Neurotic children are almost always 
poorly nourished. They have labile vasomotor systems and for that 
reason blush readily and very often have cold hands and feet. The pulse 
is apt to be rapid and undergoes a marked increase in rapidity after 
slight exertion, or as the result of the slightest nervous impression. 
These children are usually anemic ; their appetite is poor and they often 
suffer habitually from constipation. It is not infrequent for diarrhea 
to occur, particularly as the result of excitement. Cardiac palpita- 
tion is frequently complained of. Nervous vomiting is seen with chil- 
dren, girls especially, of the school age. It occurs in the morning 
immediately after breakfast, is accomplished without effort and there 
is usually no nausea. The appetite may remain fair and there is no 
vomiting at any other time. Nocturnal enuresis is found with many 
neurotic patients, and masturbation is not infrequent even in those of 
two or three years. 

Mentally, neuropathic children are apt to be bright, often preco- 
cious, but they usually show a great lack of concentration. They are 
frequently animated, talk rapidly, oftentimes stammering. They are 
never quiet, are full of restless energy, changing rapidly from one occu- 
pation to another but soon tire and constantly complain of fatigue. 
Headache is frequent and often persistent. Vague pains in almost 
every situation are complained of. Some of these children are con- 
firmed hypochondriacs. Many are affectionate and attractive, but they 
are usually self-willed and often tyrannize over the household. They are 
greatly affected by nervous impressions, often timid and readily cry 
or laugh. Tremor of the hands or eyelids is not uncommon and the 
facial phenomenon (Chvostek's symptom) is present in many. All 
sorts of habit spasm are of frequent occurrence and in rheumatic chil- 
dren chorea is a common manifestation. 



THE NEUROPATHIC DIATHESIS 265 

Sleep is usually poor. Such children have great difficulty in going 
to sleep and occasionally have night terrors. In general, nervous 
children demonstrate a combination of irritability to all impressions 
with a ready exhaustion. Untreated, they are apt to grow up into 
nervous, often hypochondriacal adults. Even with the greatest care 
and wisest treatment it is a long and tedious process to bring about 
an approach to the normal. 

Treatment consists largely in the wise management of the daily life. 
It is frequently necessary to remove the child entirely from the environ- 
ment in which he has been living. The person in charge should be one 
who will not spoil or indulge the child and will bring about a proper 
regime with a gentle but firm control. It is necessary to observe with 
the greatest care all of the measures which promote the physical wel- 
fare of the child and especially to prevent any unnecessary stimuli to 
the nervous system. 

Nervous children are much benefited by association with others 
of their own age. No greater mistake can be made than to keep such 
a child by himself for a prolonged period; but it must be remembered 
that he is usually unable to bear either the physical or the mental strain 
to which normal children are constantly subjected. For that reason 
the periods both of study and play should be short. Education at home 
is usually undesirable; but school hours must be carefully adjusted to 
the child's endurance. He should not be allowed to become either physi- 
cally or mentally exhausted. Frequent short periods of rest are neces- 
sary ; it is often desirable to keep a child in bed for two or three days once 
or twice a month. Particularly to be avoided are such things as motor- 
ing, children's parties, theaters, moving picture shows, etc. Altogether 
the most satisfactory way of bringing up such a child is in the country 
away from the excitement and distractions of city life. 

Drugs play a very insignificant part in treatment and should be 
given only for particular symptoms. Tonics, when indicated, may be 
given, but sedatives to the nervous system should be avoided. It is 
quite useless to expect relief from such operations as the removal of 
the tonsils, adenoids, circumcision, etc. Unless the necessity for them 
is plain, they often do more harm than good. 



SECTIOX III 
DISEASES OF THE DIGESTIVE SYSTEM 

CHAPTER I 
DISEASES OF THE LIPS, TONGUE, AND MOUTH 

MALFORMATIONS 

Harelip.— This is one of the most frequent congenital deformities. 
It is caused by an incomplete fusion of the central process with one or 
both of the lateral processes from which the upper half of the face is de- 
veloped. This deformity may be single or double ; the fissure is never in 
the median line, but usually just beneath the center of the nostril. There 
may be simply a slight indentation in the lip, or the fissure may extend 
to the nostril. Both single and double harelip — more frequently the lat- 
ter — may be complicated by fissure of the palate. Double harelip is 
usually accompanied by a fissure between the intermaxillary and the 
superior maxillary bone of each side. 

Cleft Palate. — This is second in frequency to harelip. It may involve 
the soft palate only, or the fissure may extend into the hard palate, pro- 
ducing a wide gap in the roof of the mouth. The most frequent form 
is that in which only the soft palate is affected. 

For the surgical treatment of both these deformities the reader is 
referred to text-books upon surgery. As to the time of operation with 
either harelip or cleft palate, — in general, operation should be performed 
as soon as the condition of the child will admit. With a vigorous child, 
it should be done in the first two weeks of life. 

If the child is premature or feeble, it is not wise to operate at once, 
but it is always to be remembered that it does not necessarily follow that 
the child's condition will be better at another time. The nutrition is 
always a matter of much difficulty and without operation a very large 
n umber of these cases die of inanition and marasmus, even with the best 
care. The medical treatment consists in the care of the mouth and in the 
nutrition of the patient. The mouth, in all cases, must be kept scrupu- 
lously clean, but the greatest care is necessary not to injure the epi- 

267 



268 DISEASES OF THE DIGESTIVE SYSTEM 

thelium. A cameFs-hair brush and plain, hike-warm water, or a weak 
alkaline solution, are to be recommended. Both of these deformities 
are exceedingly likely to be complicated by thrush. This is a serious 
menace to the success of any operation, and even to the life of the patient. 
In cases of harelip, if the fissure is so great as to interfere with nursing, 
the mother's milk should be pumped and the child fed with a spoon 
or a medicine dropper until the operation can be performed. In cleft 
palate there may be attached to the rubber nipple of the nursing bottle 
a flap of thin sheet-rubber in such a way that it closes the fissure in 
the mouth when once the nipple is in place. This flap should be shaped 
like a leaf, one extremity being sewed to the neck of the rubber nipple 
and the other end left free. In many cases, both before and immediately 
after operation, feeding by gavage may be resorted to with the greatest 
benefit and with very little inconvenience. 

Congenita! Hypertrophy of the Tongue. — This is usually due to dis- 
ease of the lymphatics, and is to be regarded as a lymphangioma. In a 
few cases hypertrophy of the muscular fibers has been present. The 
tongue may reach an enormous size, so that it is impossible for it to be 
contained within the cavity of the mouth, and it may thus interfere with 
nursing, deglutition, and even with respiration. The treatment is sur- 
gical; but some of these patients have been strikingly benefited by 
radium. 

Cases like the above are to be distinguished from those of enlarge- 
ment of the tongue seen in sporadic cretinism. In this disease the 
tongue is considerably enlarged and may protrude slightly from the 
mouth, but it is rarely, if ever, large enough to cause other symptoms. 
It diminishes notably under treatment with thyroid extract. 

Bifid Tongue. — These cases are extremely rare. Brothers has re- 
ported to the New York Pathological Society a case of cleft tongue in a 
child of one month. There was, in addition, a fissure of the soft palate. 

Tongue-tie. — This deformity is due to such a shortening of the fre- 
num that it is impossible to protrude the tongue to a normal extent. It 
differs considerably in degree in different cases. In some, the tongue 
can not be protruded beyond the gums. Tongue-tie may interfere with 
articulation, and even with sucking. The treatment consists in liberat- 
ing the tongue by dividing the frenum with scissors and completing the 
operation with the finger nail. This should be done in every case unless 
the child is a bleeder. In many cases the mother may think the tongue 
tied when the frenum is of normal length. 

Bifid Uvula. — This is not very uncommon. It usually occurs in con- 
nection with cleft palate, but is occasionally seen when there is no other 
deformity present. It may be complete or partial, and it does not of itself 
require treatment. 



DISEASES OF THE TOXGUE 269 

DISEASES OF THE LIPS 

Herpes. — Herpes labialis is an exceedingly common affection in chil- 
dren, occurring in acute febrile diseases, particularly pneumonia, and 
sometimes alone. It is the familiar "fever sore" or "cold sore" of 
domestic medicine. The appearance is similar to herpes in other parts 
of the body. There is first a group of vesicles, then rupture and the 
formation of crusts. It is often quite difficult to cure on account of the 
disposition of children to pick the lip with the fingers. Although it heals 
without treatment, recovery is facilitated by the use of some antiseptic 
lotion, such as dilute boric acid, followed by a dusting powder of zinc 
oxid and boric acid. This treatment is generally more successful than 
the use of ointments. Young children should wear mittens or elbow 
splints at night, to prevent picking at the crusts. 

Eczema of the Lip. — This is an exceedingly common condition, and 
a very troublesome one. The vermilion border is dry and rough, and 
prone to deep cracks or fissures. These are usually seen at the angles of 
the mouth or in the median line. When severe they are exceedingly 
painful, bleed freely, and are the cause of very great discomfort, es- 
pecially in the cold season. The lips should be covered at night by boric 
acid ointment, and this should be used as much as possible during the 
clay. When deep fissures form, they should be touched with burnt 
alum, or with the solid stick of nitrate of silver. Syphilitic fissures 
are considered with the symptoms of that disease. 

Perleche (French, perlecher=to lick). — This name was first given 
by Lemaistre to a form of ulceration occurring usually at the angle 
of the mouth. It begins in most cases as a small fissure, which, by 
constant licking and irritation, to which there is usually added infection, 
may develop into an intractable ulcer of considerable size. It often 
resembles the mucous patch of hereditary syphilis. The ulcer is of a 
grayish color, is quite painful, and is associated with considerable swell- 
ing of the lip. It lasts from two to four weeks. The treatment is the 
same as in simple fissure — viz., the use of burnt alum or nitrate of silver, 
and covering the part with bismuth or oxid of zinc. 

DISEASES OF THE TONGUE 

Epithelial Desquamation. — This is a disease of the lingual epithe- 
lium, which is characterized by the appearance upon the dorsum or 
margin of the tongue, of circular, elliptical, or crescentic red patches. 
with gray margins which are slightly elevated. The gray margins are 
apparently due to thickening of the epithelial layer and the red areas 



270 



DISEASES OF THE DIGESTIVE SYSTEM 



to desquamation of the epithelium. It is sometimes improperly called 
psoriasis of the tongue. It is quite a common condition, and is probably 
congenital. 

As usually seen, there exist upon the tongue from two to half a dozen 
of these red patches surrounded by a gray border, which is about one- 
twelfth of an inch wide, and slightly elevated. The outline of the patch 
is nearly always crescentic (Fig. 27). From day to day the con- 
figuration of the patches changes; the gray lines advance across the 
tongue from side to side, or from base to tip, disappearing as they reach 
the border or the extremity. They are followed by the red patches, 

and as the old ones fade away new ones form 
and run the same course. The red patches 
are of a bright color nearest the border, 
gradually shading off into the normal color 
of the tongue. Only the epithelium is in- 
volved, the deeper structures being unaf- 
fected. The duration of the disease is in- 
definite; it usually lasts for years. Guinon 
reports several cases which recovered during 
an intercurrent attack of measles or scarlet 
fever. 

The cause is unknown. The condition 
occurs rather more frequently in females 
than in males, and Gubler has reported an 
instance of several members of the same 
family being affected. The condition has 
been thought to depend upon nearly every disease of childhood. It is 
not accompanied by pain, salivation, or by other symptoms of stomati- 
tis, and is of little practical importance. Its symptoms are so char- 
acteristic that it can hardly be mistaken for any other condition. Treat- 
ment is unnecessary. 

Two other forms of epithelial desquamation have been observed, 
both much more rare than that described. In one of these the red de- 
nuded portion occupies the margin of the tongue, while the center is 
gray or white; the irregular wavy outline which separates the two sug- 
gests strongly an outline map, and the condition is sometimes called the 
geographical tongue." This term is frequently employed to designate 
the common form. In another variety nearly the whole organ may be 
uniformly red, from loss of the epithelium, there being no borders or 
patches. Both these varieties are of much shorter duration than the 
more common form, usually lasting only a few weeks. 

Glossitis. — Inflammation of the tongue is not very common in chil- 
dren. It is usually of traumatic origin. The injury may be due to bit- 




Fig. 27. — Epithelial Desqua- 
mation of the Tongue. 
(Guinon.) 



DISEASES OF THE TONGUE 271 

ing the tongue in a fall or in an epileptic seizure. Glossitis is sometimes 
excited by the irritation of a sharp tooth, causing a -wound which may be 
the avenue of infection; or it may result from taking into the mouth 
irritant or caustic poisons. In a small number of cases no cause can be 
found. The symptoms are marked swelling of the tongue, so that it may 
protrude from the mouth ; and it may even be so great as to cause severe 
dyspnea. There are also seen profuse salivation, difficulty in swallowing 
and in articulation, and often considerable local pain. There may be a 
rise of temperature to 102° or 103° F. The treatment consists in the 
use of fluid food, which in severe cases may be introduced through 
the nose by means of a catheter. Ice may be used externally, or, bet- 
ter still, pieces of ice may be kept in the mouth continually. If there 
is obstruction to respiration, and in all severe cases, scarification 
should be done on the dorsum of the tongue along the side of the 
raphe. 

The acute swelling of the tongue and lips occurring in some cases of 
urticaria may be mentioned in this connection. This is a rare condi- 
tion in children, but it may develop rapidly and to such a degree as to 
cause alarming symptoms. The treatment consists in the use of ice 
locally, free purgation by salines, and, in extreme cases, needle punc- 
tures to relieve the edema. 

Tongue-swallowing'. — This term is used to describe a rare condition 
seen in infants, in which the tongue is turned backward into the 
pharynx, so as to obstruct respiration. It may be drawn quite into 
the esophagus. Several marked cases have been collected by Hennig. 
While most frequently occurring with paroxysms of pertussis, tongue- 
swallowing has been seen in other diseases. This should not be forgot- 
ten as one of the explanations of sudden asphyxia in a young infant. 
The conditions necessary for its production are a somewhat relaxed organ 
or a long frenum. In none of the fatal cases reported, however, had the 
frenum been divided. In some weak infants, falling back of the tongue, 
so that its base partly covers the epiglottis, produces asphyxia, precisely 
as it occurs in adult life under full anesthesia. The recognition of the 
condition is a very easy one, and its treatment is to relieve the obstruc- 
tion by drawing the tongue forward by the finger or forceps. 

Ulcer of the Frenum. — The friction against the sharp edges of the 
lower central incisors frequently causes an ulcer of the frenum in in- 
fants. We have never seen it in older children. It usually occurs in 
pertussis, but is seen in other conditions. In some it appears to be pro- 
duced by friction of the teeth during nursing from the breast or bottle. 
It is more often seen in children who are delicate or cachectic than in 
those who are healthy and well nourished. The ulcer may be confined 
to the frenum, or it may extend quite deeply into the tongue. It is 



272 DISEASES OF THE DIGESTIVE SYSTEM 

usually about one-fourth of an inch in diameter, and of a yellowish-gray 
color. When not readily cured by touching with alum or nitrate of 
silver, the child may be fed by gavage for several days, or the teeth may 
be covered by a bit of absorbent cotton. 



DENTAL CARIES 

Although the teeth do not strictly belong to the province of the physi- 
cian, they have an important influence upon the general health. The 
pernicious effects of dental caries have only recently been appreciated. 
Eoutine examinations of public-school children, made in various cities, 
have shown that fully 80 per cent have extensive dental caries. Among 
the inmates of institutions the proportion is fully as great as this, possi- 
bly greater, unless, as in a few modern institutions, special attention is 
given to this subject. 

Among the causes of dental caries the most important without doubt 
is want of cleanliness — the almost entire neglect of the toothbrush 
among the children of the poor. This leads to decomposition of food 
and secretions, acid fermentation, erosions of the enamel, etc. But not 
all caries of the teeth can be ascribed to this cause. Diet has certainly 
much to do with it. It is our belief that the opinion commonly held, 
that excessive indulgence in sweets is responsible for dental caries, is 
well founded. Malnutrition and improper food, especially in early 
childhood, certainly affect the teeth. In some children a congenitally 
defective enamel is present. Hereditary syphilis is also a cause, and in 
children with congenital mental defects the teeth are prone to early 
decay. 

The symptoms are, both local and general. Locally, as a result of 
decomposition and infection, there are present foul breath, gingivitis, 
alveolar abscess, ulcerative stomatitis, toothache, etc. The lymph nodes 
in the neighborhood frequently become enlarged and sometimes tuber- 
culous. Tuberculosis of the submaxillary and submental lymph nodes 
is nearly always the result of infection through the teeth or the gums. 
Whether the cervical lymph nodes are infected in the same way 
is very doubtful. The general symptoms result in part from improper 
mastication of food and in part from sepsis from the local condition. 
There may be seen only failing nutrition, loss of appetite and anemia; 
or these symptoms may be accompanied by a slight but continuous fever 
which may persist for months. In more marked cases there may be 
symptoms of a pyemic character; higher temperature, joint swellings, 
wasting, etc. Many cases of illness diagnosticated acute rheumatism 
and accompanied by cardiac complications have their origin in oral 



DIFFICULT DENTITION 273 

sepsis at the basis of which are carious teeth, and no treatment has 
any influence upon the condition until these are removed. 

From the local irritation various nervous symptoms may arise. 
The most common are habit spasm, facial chorea, headaches, and, ac- 
cording to some writers, even epileptiform convulsions. The presence 
of carious teeth is a menace to the general health. They certainly pre- 
dispose to local tuberculosis. Many persons assume that if the teeth 
affected belong to the first set, it matters little. However, the perma- 
nent teeth are often injured by extensive decay of the deciduous set. 
The treatment of this condition belongs to the dentist ; but the physician 
should appreciate the importance of the subject and urge parents and 
others in charge of children to give proper attention to cleanliness and to 
see that carious teeth of the first set are either filled or removed. 



ALVEOLAR ABSCESS 

This is common in children, especially among the class of hospital 
and dispensary patients, in whom little or no attention is given to the 
care of the teeth. It causes severe pain and acute swelling, which may be 
limited to the gum, or it may involve to a considerable extent the perios- 
teum of the jaw and even cause swelling of the whole side of the face. 
If there is retention of pus, there may be quite severe constitutional 
symptoms, such as chills and high temperature; but in most of the 
cases these are wanting. The abscess usually opens spontaneously into 
the mouth, but it may open externally if the molar teeth are the ones 
affected. It may even lead to necrosis of the jaw. If its site is the upper 
jaw, the pus may find its way into the nasal cavity or into the maxillary 
sinus. 

The treatment is, in the first place, prophylactic. This requires at- 
tention to the teeth to prevent decay, and the removal of old carious 
fangs, which are a constant menace to the health of the child. The free 
use of the toothbrush and some antiseptic mouth-wash will, in the 
great majority of cases, prevent the occurrence of this disease. It is 
important that the abscess be opened early and free drainage secured. 
If there is a carious tooth it should be drawn. 



DIFFICULT DENTITION 

The place of dentition as an etiological factor in the diseases of in- 
f.Hicy is one which has given rise to much discussion. From a very early 
period the view has descended, that a large number of the diseases occur- 



274 DISEASES OF THE DIGESTIVE SYSTEM 

ring between the ages of six months and two years are due to difficult 
dentition. The list of such diseases is a long one, but year by year it has 
been shortened as one after another has been shown to depend upon 
other causes, dentition being only a coincidence. 

At the present time many good observers deny that dentition is ever 
a cause of symptoms in children; some even going so far as to say that 
the growth of the teeth causes no more symptoms than the growth of the 
hair. Without doubt the usual mistake made in practice is to overlook 
disease of the brain, ears, lungs, stomach, and intestines, because of the 
firm belief that the child was "only teething." The physician who 
starts out with the idea that in infancy dentition may produce all symp- 
toms usually gets no further than this in his etiological investigations. 
Although no doubt the importance of dentition as an etiological factor 
in disease has been in the past greatly exaggerated, the careful and 
candid observer must admit that, particularly in delicate, highly nervous 
children, dentition may produce many reflex symptoms, some even of 
quite an alarming character. 

Speaking from general impressions not from statistics, we should say 
that in our experience fully one-half of the healthy children cut their 
teeth without any visible symptoms, local or general; in the remainder 
some disturbance is usually seen, and though in most cases it is slight 
and of short duration, it may last for several days or even a week. The 
symptoms most commonly seen are disturbed sleep, or wakefulness at 
night and fretfulness by day, so that children often sleep only one-half 
the usual time. There is loss of appetite, and much less food than usual 
is taken. There is often, but not always, an increase in the salivary 
secretion, a slight amount of catarrhal stomatitis, and a constant dispo- 
sition on the part of the child to put the fingers into the mouth. The 
bowels are often constipated or there may be slight diarrhea. The ther- 
mometer may show a slight elevation of temperature to 100° or 101.5° 
F. The weight often remains stationary for a week or two, and there 
may even be a loss of a few ounces. The duration of these symptoms in 
most cases is but a few days, and they require no special treatment. If 
the food is forced beyond the child's inclination, attacks of indigestion 
with vomiting and diarrhea are easily excited. 

Symptoms more severe than the above, are rare in healthy children, 
but are not infrequent in those who are delicate or rachitic. In such 
susceptible children, even so slight a thing as dentition may be an excit- 
ing cause of quite serious disturbances. Often there is some other 
factor in the case, such as bad feeding or feeble digestion. In delicate 
or rachitic children there may be seen the symptoms already mentioned 
as occurring in healthy infants, but in greater severity ; and in addition 
there may be severe attacks of acute indigestion. Occasionally there is 



DIFFICULT DENTITION 275 

an elevation of temperature to 102° or 103° F., lasting usually only two 
or three clays, and accompanied by no symptoms except almost complete 
anorexia. It is occasionally, but rarely, seen that a child will have con- 
vulsions just before or during the eruption of each tooth. Such chil- 
dren are almost always the subjects of latent tetany, dentition acting 
as any other exciting cause to determine the onset of the convulsions. 
In cases of eczema the symptoms often undergo a distinct exacerba- 
tion with the eruption of each group of teeth. As regards almost 
all the other diseased conditions which are commonly attributed to 
dentition, we believe that it is a delusion to ascribe them to this 
cause. 

The physician should watch a child carefully, and examine him fre- 
quently, to be sure that he is not overlooking some serious local or con- 
stitutional disease before he allows himself to make the diagnosis of 
difficult dentition. Probably in ninety-five per cent of the cases in which 
symptoms are present, they are due to some cause other than dentition. 
When, however, symptoms such as any of those mentioned disappear 
immediately when the teeth come through, and when we see them 
repeated four or five times in the same child with the eruption of each 
group of teeth, and accompanied by red and swollen gums, we can 
not escape the conclusion that dentition is a factor in their production, 
though perhaps not the only one. 

In the treatment of this condition drugs occupy but a small place. It 
should be remembered that infants are at this time in a peculiarly sus- 
ceptible condition as regards the digestive tract, and attacks of indiges- 
tion, and even severe diarrhea, are readily excited from slight causes, 
especially from overfeeding. Special care should be exercised in this 
respect. The strength of the food should be reduced, as well as the 
amount given. A poor appetite indicates a feeble digestion, which 
should not be overtaxed. As attacks of bronchitis and acute nasal ca- 
tarrh are readily induced, even slight exposure should be guarded 
against. The nervous symptoms, when severe, may be relieved by the 
use of moderate doses of the bromids or by phenacetin, better than by 
opiates. All soothing syrups should be discountenanced. All the vari- 
ous devices for making dentition easy are a delusion. In a small num- 
ber of cases lancing the gums is of value. We have seen in a few rare 
instances marked and undoubted relief given by it. This is likely to 
be the case only when the gums are tense, swollen, and very red, with the 
teeth just beneath the mucous membrane. To press a tooth through the 
gum by simply rubbing gently with the finger covered with sterile gauze 
is frequently more effective than an incision. It seldom happens, how- 
ever, that the relief expected is seen from any of the measures men- 
tioned. 



276 DISEASES OF THE DIGESTIVE SYSTEM 

CATARRHAL STOMATITIS 

This is characterized by redness and swelling of the mucous mem- 
brane, and by increased secretion of the salivary and the muciparous 
glands of the mouth. It usually involves a large part of the mucous 
membrane. 

Etiology. — Catarrhal stomatitis may result from traumatism. This 
injury may be mechanical, or due to heat or any irritant accidentally 
taken into the mouth. It frequently occurs at the time of the eruption 
of a tooth. It complicates measles, scarlet fever, diphtheria, influenza, 
and many other infectious diseases. In these cases and in many others 
the disease is probably due to direct infection. 

Lesions. — The lesions are essentially the same as in catarrhal inflam- 
mation of other mucous membranes. There is congestion with des- 
quamation of epithelial cells and sometimes the formation of superficial 
ulcers. The process may be a very superficial one, or it may extend to 
the submucous tissue. 

Symptoms. — The mucous membrane is intensely injected, all the 
capillaries are dilated, and small hemorrhages easily excited. The mu- 
cous membrane is swollen, this being most apparent over the gums or 
about the teeth. There may be some swelling of the lips. The mouth 
seems hot, and the local temperature is certainly increased. There is 
considerable pain, as shown by fretfulness, but particularly by the disin- 
clination to take food : infants, though evidently hungry, either refusing 
the breast or bottle altogether, or dropping it after a few moments. The 
increase in secretion is sometimes marked, so that the saliva pours from 
the mouth, irritating the lips and face and drenching the clothing. In 
other cases the saliva is swallowed. On close inspection there may be 
seen swelling of the muciparous follicles, and even the formation of tiny 
cysts from the accumulation of secretion within them. The tongue is 
usually coated, the edges reddened, and the papillae prominent. In 
febrile diseases, such as typhoid, etc., we may get an accumulation of 
dead epithelium with the formation of cracks and fissures of the tongue, 
and the lips may present a similar condition. The neighboring lym- 
phatic glands are slightly enlarged and tender. The constitutional symp- 
toms accompanying simple stomatitis are not severe, but some disturb- 
ance is almost always present. There may be derangement of digestion 
with vomiting, and even a mild attack of diarrhea. In the majority of 
cases the disease runs a short course, recovery taking place in a few 
clays when the primary cause is removed. In very delicate children it 
may be prolonged, and from the interference with nutrition may even 
lead to serious consequences. 



HERPETIC STOMATITIS 277 

Treatment. — The mouth and teeth should be kept clean. Food is 
more acceptable if given cold. In very severe cases, when food is refused, 
gavage may be resorted to three or four times daily. In all cases chil- 
dren may be given ice to suck. This is refreshing, both on account of 
the cold and from the relief to the thirst. The mouth should be kept 
clean with a solution of boric acid, ten grains to the ounce, or an alkaline 
solution, such as DobelPs, diluted with an equal amount of cold boiled 
water; or plain water may be used. In the severe forms, where there is 
much swelling and slight catarrhal ulceration, astringents are required. 
In our experience alum is the best; this may be applied in the form of 
the powdered burnt alum mixed with an equal amount of bismuth, or in 
solution, ten grains to the ounce, with a swab or brush. Where ulcers 
are slow in healing and very painful, the powdered burnt alum or the 
solid stick of nitrate of silver may be applied directly. 



HERPETIC STOMATITIS 

(Aphthous, Vesicular, or Follicular Stomatitis) 

In this form of stomatitis we have the appearance first of small 
yellowish-white isolated spots, and subsequently the formation of super- 
ficial ulcers: These ulcers are first discrete, but may coalesce and form 
others of considerable size. It is a self-limited disease, usually running 
its course in from five days to two weeks. 

Etiology. — Very little is as yet positively known regarding the cause 
of herpetic stomatitis. It is not common in the first year, but after that 
is very frequently seen throughout childhood. It occurs in the strong as 
well as in the delicate. It is often associated with some disturbance of 
the stomach, and occasionally with dentition. We have adopted the term 
herpetic, because the condition is analogous to herpes of the lips and 
face, the difference in appearance being due chiefly to location. It is 
apparently caused by something which acts upon terminal nerve fila- 
ments. 

Lesions. — The generally accepted opinion is that there is first a. vesi- 
cle, followed by a death of epithelial cells covering it, and then a super- 
ficial ulcer. The white appearance is due to the fact that the ulcers, 
being on a mucous membrane, are always moist. These ulcers may 
extend superficially, but never deeply; they heal quickly with the for- 
mation of new epithelial cells, leaving no cicatrices. Herpetic stoma- 
titis is always associated with more or less catarrhal inflammation. 

Symptoms. — The disease is characterized by local and general symp- 
toms. The latter are quite indefinite — general indisposition, loss of 



278 DISEASES OF THE DIGESTIVE SYSTEM 

appetite, and slight fever. The local symptoms consist in the develop- 
ment of small, shallow, circular ulcers, usually coming in successive 
crops. While most frequent at the border of the tongue and the inside 
of the lips, they may be found upon any part of the mucous membrane 
of the mouth or the pharynx. There may be only half a dozen present, 
or the mouth may be filled with them. They are first of a yellowish 
color, and on an average about one-eighth of an inch in diameter. By 
the coalescence of several smaller ulcers there may form patches of con- 
siderable size, sometimes nearly covering the lips. The older ulcers are 
apt to have a dirty-gray color, and in places may look not unlike a 
diphtheritic membrane. The smaller ones are surrounded by a red 
areola, and when healing the margin is of a bright red color. Their 
appearance is often more like that of an exudation upon the mucous 
membrane than an ulceration. The other symptoms are much the 
same as those of catarrhal stomatitis, but usually of greater severity. 
The pain is particularly intense, it being often difficult to induce chil- 
dren to take anything in the form of food. The tongue is frequently 
coated, but there is never the foul breath of ulcerative stomatitis. The 
duration of the disease is from one to two weeks, and, if the child is in 
good condition, complete recovery takes place even without any special 
treatment. In badly nourished children the disease may last for two or 
three weeks; relapses may occur, and the condition may interfere very 
seriously with the child's nutrition. 

Treatment. — This is the same as in catarrhal stomatitis, with the 
addition that to each one of the ulcers finely powdered burnt alum should 
be applied with a camel's-hair brush. If this is not effective, the solid 
stick of nitrate of silver may be used. The ulcers will usually yield rap- 
idly to this treatment. In our experience, drugs given with the purpose 
of affecting the lesion in the mouth have been without benefit. 



ULCERATIVE STOMATITIS 

Ulcerative stomatitis is believed to occur only when teeth are pres- 
ent. It is characterized by an ulcerative process, beginning at the junc- 
tion of the teeth and the gum, and extending along the teeth ; it occa- 
sionally involves other parts of the mouth, but never spreads beyond the 
buccal cavity. 

Etiology. — A form of ulcerative stomatitis is produced by certain 
metallic poisons, especially mercury, lead, and phosphorus ; but all these 
are now rare. Ulcerative stomatitis also occurs in scurvy; and it seems 
probable that an allied disturbance of nutrition, with spongy, swollen 
gums, precedes some other forms of ulcerative stomatitis. Bad sur- 



ULCERATIVE STOMATITIS 279 

roundings and improper food act as predisposing causes; for the disease 
is quite common in institutions for children and in hospital and dis- 
pensary patients, although rare in private practice. Local causes of im- 
portance are want of cleanliness of the mouth and teeth and the presence 
of carious teeth. Conditions which produce a lowered vitality of the 
gums act as predisposing causes, and infection as an exciting cause of 
the disease. The constant clinical features of ulcerative stomatitis and 
the occasional occurrence of epidemics indicate a specific cause which is 
probably the same as that of ulceromembranous tonsillitis. The two 
conditions often exist at the same time. From the investigations of Yin- 
cent, Bernheim, Plaut and others it seems probable that noma is also 
produced by the same organism but represents a more virulent infection. 

Lesions. — The disease may begin at any part of the mouth, but most 
frequently upon the outer surface of the gum along the lower incisor 
teeth. From this point it extends behind the teeth, and from the in- 
cisors to the canines and molars, usually of one side only; but it may 
involve the entire gum of both jaws. From the gums the process may 
spread to the lips, affecting the fold of mucous membrane between the 
giun and the lip, and also to the inner surface of the cheek, especially 
opposite the molar teeth, where large ulcers often form. In neglected 
cases the disease may extend into the alveolar sockets, the teeth loosen- 
ing and falling out. The periosteum of the alveolar process may be in- 
volved, and even superficial necrosis of the jaw may occur, as has hap- 
pened in several cases that came under our observation. These severe 
forms are met with in institutions chiefly and then generally follow 
measles or scarlet fever. 

Ulcers similar in appearance may also be present in other parts of 
the mouth — i. e., on the soft palate or the tonsils, sometimes even when 
the gums are not involved. 

Symptoms. — The first things noticed are the very offensive breath and 
the profuse salivation. It is usually for one of these symptoms that 
the patient is brought for treatment. On inspection of the mouth, there 
are seen in the mild cases, swollen, spongy gums of a deep-red or purplish 
color, which bleed at the slightest touch. There is a line of ulceration, 
usually along the incisor teeth, most marked in front, which may ex- 
tend to any or to all of the teeth; sometimes it affects only the gum 
along the molar teeth, the incisors escaping. At the junction of the 
teeth and gum is seen a dirty, yellowish deposit, on the removal of which 
free bleeding takes place. The diseased parts are very painful, and the 
child cries and resists any attempt at examination. In the more severe 
cases and in those of longer duration the teeth are loosened, sometimes 
being so loose that they can be picked from the gum. There may be 
necrosis of the jaw, and even a loose sequestrum may be found. In 



280 DISEASES OF THE DIGESTIVE SYSTEM 

these cases the ulceration along the gums is deeper, and there may be 
ulcers in the cheek opposite the molar teeth, or inside the lip. The 
swelling may be so great that the teeth are almost covered; this is seen 
particularly in the scorbutic form. The saliva pours from the mouth, 
adding greatly to the discomfort of the patient. Beneath the jaw are 
felt the large, swollen lymphatic glands, which are painful and tender to 
the touch, but show no tendency to suppurate. The tongue is somewhat 
swollen, and shows at the edges the imprint of the teeth; it has a thick, 
dirty coating. 

The disease is attended by little or no fever or other constitutional 
symptoms. The general condition of these patients is often poor, and 
there may be quite a marked cachexia. Other forms of stomatitis may be 
associated, and it should not be forgotten that the gangrenous form may 
follow. 

When not recognized or not properly treated, ulcerative stomatitis 
may last for months. When properly treated it tends in all recent cases 
to recovery, usually in from five to ten days. No deformity of the mouth 
is left, the only untoward results being shrinking of the gum, sometimes 
loss of some of the incisor teeth, and more rarely a superficial necrosis 
of the alveolar process. All these are quite uncommon. Ulcerative 
stomatitis can hardly be confounded with any other form, and not only 
should a diagnosis of the lesion be made, but the condition upon which 
it depends should, if possible, be discovered; scorbutus, particularly, 
should not be overlooked. 

Treatment. — The first thing to be done is to remove the cause. When 
dependent upon metallic poisoning the source should be discovered. 
Scorbutic cases should have the usual anti-scorbutic diet. Cleanliness of 
the mouth is of great importance, and this may best be accomplished by 
the use of peroxid of hydrogen diluted with from one to four parts of 
water. It should be followed by thorough rinsing with plain water, and 
repeated several times a day. In other cases a solution of alum, five 
grains to the ounce, or a mouth-wash of chlorate of potash, three grains 
to the ounce, may be employed. The only objection to the last men- 
tioned is the pain which it sometimes produces. A strip of gauze between 
the cheek and the gums aids greatly in cleanliness. This may be 
left in place and affords no inconvenience, but on the contrary, comfort 
to the patient. 

The specific remedy for ulcerative stomatitis is chlorate of potash. 
The best method of administration is to give two grains, or one-half tea- 
spoonful of a saturated solution, largely diluted, every hour during the 
day for the first twenty-four hours and subsequently every two hours; 
when improvement occurs the dose may be still further reduced. Marked 
benefit is usually seen in one or two days even in cases that have lasted 



THRUSH 281 

for several weeks. If the case does not yield readily to this treatment 
there is probably disease at the roots of the teeth, and when loose these 
should be removed, and the jaw examined to see if there is necrosis. 
Occasionally when there is no disposition to heal, the shreds of necrotic 
tissue should be carefully removed, and burnt alum or nitrate of silver 
applied. 

The constitutional and dietetic treatment in all these cases should 
be the same as that employed in scurvy — i. e., plenty of fruit, fresh vege- 
tables, and sometimes the internal administration of mineral acids, espe- 
cially aromatic sulphuric acid. Iron is indicated in most of the cases. 

Ulceration of the Hard Palate. — This is usually seen in the first few 
weeks of life, but may occur in any child suffering from marasmus. The 
primary cause is often the injury inflicted in cleansing the mouth. In 
other cases it is due to the friction of the rubber nipple, or some other 
object which the child is allowed to suck. In still others it is appar- 
ently produced by the habit of tongue-sucking frequently observed in 
these young infants. The appearances are quite characteristic: there is 
found, rather far back upon the hard palate, usually in the middle line, 
a superficial ulcer, from a fourth to a half inch in diameter. There are 
no signs of acute inflammation. Thrush may coexist, but it has no rela- 
tion to the production of the disease. Spontaneous recovery usually oc- 
curs in from one to three weeks, provided the cause can be removed. In 
children suffering from marasmus these ulcers are very intractable, and 
in many instances their cure is practically impossible. It is therefore 
especially important to prevent, if possible, their formation by care in 
cleansing the mouth, and in avoiding the other causes referred to. When 
ulcers have appeared they should be treated as in cases of herpetic 
stomatitis. 

THRUSH 

(Sprue; German, Soor; French, Muguet) 

Thrush is a parasitic form of stomatitis characterized by the appear- 
ance upon the mucous membrane, usually of the tongue or the cheeks, 
of small white flakes or larger patches. It is common in infants of the 
first two or three months, and in all the protracted exhausting diseases 
of early life. 

Etiology. — The exact class to which the vegetable parasite which pro- 
duces thrush belongs has not yet been definitely settled. Robin's opinion 
was long accepted that it was the o'idium albicans; the view of Grawitz, 
that it is the saccharomyces albicans, is now more generally adopted. If 
a little of the exudate from the mouth is placed upon a slide and a 



DISEASES OF THE DIGESTIVE SYSTEM 

,1,,,,, f liquor- potassae added, the structure of the fungus is readily 
>IM . M . \\ith the low power of the microscope there can be made out 
one threads (the mycelium) and small oval bodies (the spores). With 
a high power the threads can be seen to be made up of a number of 
r rods, at the ends of winch the spore formation takes place (Fig. 
The mycelium is produced from the spores. The spores of this 
fungua are of very common occurrence in the atmosphere. It is difficult 
or impossible lor thrush to develop upon a healthy mucous membrane. 
[t8 growth is favored by slight abrasions, such as are often produced by 
rough methods of cleansing the mouth; also by catarrhal stomatitis, a 

scanty salivary secretion and 
want of cleanliness. The na- 
ture of the process which it 
produces is in all probability 
a sugar fermentation, the acid 
reaction of the mouth being 
the result of the growth rather 
than its cause. Infection may 
come from another patient by 
means of a rubber nipple or a 
cloth which has been used for 
the infected mouth, from the 
nipple of the nurse, or directly 
from the air. Its production 
is favored by a scanty secre- 
tion of saliva, hence it is fre- 
quent in the first two or three 
months of life; also by an altered secretion such as is seen in protracted 
wasting diseases, enterocolitis, marasmus, typhoid, tuberculosis, etc. It 
i- very common in infants suffering from harelip or any other deformity 
of th<- mouth. The disease is frequently seen in foundling asylums, in 
all places where many young infants are crowded together, and where 
cleanliness of months, bottles, etc., is neglected. 

Lesions. The spores lodge between the epithelial cells and gradually 
Karate the differed layers. This occurs before the formation of the 
wnite Pellicle. Later the disease spreads on the surface of the mucous 
membrane, and also penetrates the deeper structures. It may invade 
the blood-vessels and cause thrombosis or even be carried to distant parts. 
Although the saccharomyces albicans is commonly found upon flat epi- 
thelium, its growth is not confined to it. It usually begins at many 
l,8t,nd P° inta u P° n i 1 " 1 mucous membrane, and gradually spreads until 
8 kkes place; a continuous membrane may be thus formed. 
No put u produced by the process. 




28. — Thbubh Fungus (highly magnified)- 
a, mycelium; h, spores; c, epithelial cells 
from the mouth; d, leucocytes; e, detritus. 
( v. Jaksch.) 






THRUSH 283 

The usual seat is the margin of the tongue, the inside of the lips and 
cheeks, and the hard palate, but not infrequently it involves the pillars 
of the fauces, and the entire pharynx. Further extension in the digestive 
tract than this is rare, although the esophagus, the stomach, and even the 
intestines, may be invaded. We have seen it but once or twice in the 
esophagus and never in the stomach, and we know of but two reported.^ 
cases in this country in which thrush has been found there. Cases in- 
volving the esophagus and the stomach appear from reports to be much 
more common in Europe. In a few cases in the Babies' Hospital the sac- 
charomyces albicans has been found in the lungs of infants suffering 
from bronchopneumonia. There are several reported cases of general 
blood infection from this organism. 

Symptoms. — The essential symptoms of thrush are the appearance 
upon the mucous membrane of the mouth — usually beginning upon the 
tongue or the inner surface of the cheek — of small white flakes which 
resemble deposits of coagulated milk, but which differ from them in the 
fact that they can not be wiped off. If forcibly removed, they usually 
leave a number of bleeding points. There may be only a few scattered 
patches, or the mouth and pharynx may be covered. The mouth is gen- 
erally dry and the tongue coated; food may be refused on account of 
pain, and there may be some difficulty in swallowing. The other symp- 
toms depend upon the conditions with which the thrush is associated. 

Diagnosis. — This is rarely difficult. The deposit may be mistaken for 
coagulated milk, but is distinguished by the features just mentioned. 
When existing upon the pharynx and fauces it has been confounded with 
diphtheria, although this mistake can hardly be made if all the facts 
of the case are taken into consideration — the age of the patient, the 
involvement of the lips and tongue, the dry mouth, the absence of gland- 
ular enlargement, etc. In any case of doubt the examination of the 
deposit under the microscope at once reveals its true nature. 

Prognosis. — Thrush is not in itself a dangerous disease, except in the 
very rare instances where it may obstruct the esophagus, and this can 
hardly occur except in a condition of exhaustion which is necessarily 
fatal. In a feeble and delicate infant, or in one with harelip or cleft 
palate, thrush may be a serious complication. With proper treatment 
most of the cases involving only the mouth are readily cured. 

Treatment. — Thrush may usually be prevented by due attention to 
cleanliness of the mouth, rubber nipples, bottles, cloths, etc. In infants 
with deformities of the mouth in institutions, it frequently develops 
despite all precautions. All rubber nipples should be kept in a solution 
of boric acid and the child's mouth should be cleansed several times a 
day. On no account should a feeding-bottle be passed from one child 
to another. 



284 DISEASES OF THE DIGESTIVE SYSTEM 

In the treatment of the disease the essential things are cleanliness, 
and the use of some mild antiseptic mouth-wash. The best routine treat- 
ment is to cleanse the mouth carefully after every feeding or nursing 
with a solution of bicarbonate of soda, and to apply twice a day a one- 
per-cent solution of formalin. All applications should be carefully made, 
so as not to injure the epithelium. The best method of cleansing is by 
a small swab made with a wooden toothpick and absorbent cotton. Ap- 
plications to be especially avoided are those mixed with honey or any 
syrup. In hospital cases the disease seems to be prolonged by the irrita- 
tion of the rubber nipple of the feeding-bottle. In such it has been 
our practice to feed by gavage for two or three days, as some cases im- 
proved much more rapidly when this was done. 



GONORRHEAL STOMATITIS 

There has been described by Dohrn and Rosinski a form of stomatitis 
in the newly born, due to a gonorrheal infection. This is not likely to 
take place unless the epithelium has been removed. The infection in all 
cases occurred from the mother. The lesion consists in the formation of 
yellowish-white patches upon the tongue or hard palate — regions in 
which the epithelium is liable to be injured by rough attempts at cleans- 
ing the mouth. There may be other evidences of gonorrheal infection 
especially ophthalmia. The diagnosis rests upon the discovery of the 
gonococcus in the exudate. In all the cases cited the general health was 
not affected, and recovery followed in the course of a week or ten days. 

The treatment consists in thorough cleanliness and in the application 
of a saturated solution of boric acid or of formalin, as in thrush. 



SYPHILITIC STOMATITIS 

The buccal symptoms of hereditary syphilis are important both from 
a diagnostic and a therapeutic standpoint. The most frequent lesions are 
fissures, ulcers, and mucous patches. Fissures are found upon the lips, 
most frequently at the angle of the mouth, and are usually multiple. 
They may be quite deep and cause frequent hemorrhages. Mucous 
patches are superficial ulcers developing from papules which form upon 
the mucous or mucocutaneous surfaces. In cases of acquired syphilis 
in children the primary sore may be seen upon the tongue, the lip, or the 
tonsil. All these symptoms are more fully considered in the chapter on 
Syphilis. 



GANGRENOUS STOMATITIS— NOMA 285 



DIPHTHERITIC STOMATITIS 



In severe cases of diphtheria the membrane is fonnd not only upon the 
pharynx and tonsils, but it may appear anywhere upon the buccal 
mucous membrane or the lips. It is questionable whether the diphther- 
itic process ever begins on the mucous membrane of the mouth, or is 
ever limited to this part. In our own experience diphtheritic stomatitis 
has always been associated with deposits upon the tonsils and pharynx. 
It is seen only in the severest cases, and in those which, from other con- 
ditions present, are almost necessarily fatal. Bearing in mind the above 
points, it can hardly be mistaken for any other variety of stomatitis, 
although not infrequently the mistake is made of regarding as diph- 
theritic, cases of herpetic stomatitis in which the ulcers have coalesced. 
The treatment, so far as the mouth is concerned, consists in cleanliness 
by frequent gargling or irrigation with a hot saline solution. Forcible 
removal of the membrane is not to be advised. 



GANGRENOUS STOMATITIS— NOMA 
(Cancrum oris) 

The term noma is used to designate all forms of spontaneous gan- 
grene occurring in children, which involve mucous membranes or muco- 
cutaneous orifices. The most frequent situation being the mouth, noma 
and gangrenous stomatitis are often used synonymously. Noma may, 
however, affect the nose, external auditory canal, vulva, prepuce, or anus. 
It is a rare disease, and usually terminates fatally. 

Etiology. — Noma is seldom seen outside of institutions for children, 
where small epidemics are not uncommon. It is usually secondary to 
some of the infectious diseases, most frequently following measles, and 
next to this scarlet fever, typhoid, or whooping-cough. While it may 
occur at any age, most of the cases are in children under five years, and 
in those of poor general condition. Noma seldom attacks parts previ- 
ously healthy. In the mouth it may be preceded by catarrhal, or more 
often by ulcerative stomatitis; in the auditory canal, by a chronic otitis 
media. There seems little doubt that the disease is contagious. We 
once saw five cases in a single ward, all beginning in the auditory 
canal, which were apparently produced by the use of the same syringe 
to clean the ears without proper disinfection. All these children were 
suffering from whooping-cough at the time. 

It is now quite well established that the exciting cause of noma is the 
11 



280 DISEASES OF THE DIGESTIVE SYSTEM 

same as that of ulcerative stomatitis (q. v.). The pathological process 
in one case is of a mild type occurring in patients of considerable 
resistance. In the other it is of a severe or malignant type occurring in 
patients of feeble resistance as a result of previous acute disease. In 
the gangrenous tissue pyogenic cocci and putrefactive bacteria are 
abundant. In the border zone, and extending into the adjacent healthy 
tissue the specific organisms of the disease are usually found. 

Lesions. — The process is one of slowly spreading gangrene. In most 
of the cases there are thrown out inflammatory products in quite large 
amount, but there is little or no tendency to limitation of the disease. 
This usually advances steadily until death occurs. In a small number of 
cases a line of demarcation finally forms and the slough separates, leav- 
ing a large area to be partially filled in by granulation and cicatrization. 
Other infectious processes are likely to accompany the disease, partic- 
ularly bronchopneumonia. 

Symptoms. — The constitutional symptoms are not usually severe until 
the local disease has existed for several days. Then those of marked 
prostration and sepsis develop, sometimes quite rapidly. The tempera- 
ture is usually elevated to 102° or 103° F., and sometimes to 104° or 
105° F. There is dulness, apathy, feeble pulse, muscular relaxation, 
and very often diarrhea. Before death the temperature may be sub- 
normal. 

Of the local symptoms, often the first to attract attention is the odor 
of the breath; sometimes it is the dusky spot on the cheek or lip. On 
examination of the mouth, there usually is found upon the gum or inside 
of the cheek a dark, greenish-black necrotic mass, surrounded by tissues 
which are swollen and edematous, so that the cheek or lips may be 
two or three times their normal thickness. Externally the parts are 
tense and brawny from the swelling, this infiltration always extending 
for some distance beyond the gangrenous part. As the process extends, 
the teeth loosen and fall out ; there may be necrosis of the alveolar process 
of the jaw and perforation of one or both cheeks or lower lip; ex- 
tensive sloughing of the face may take place, usually upon one side, 
sometimes upon both, giving the patient a horrible appearance. In one 
patient the process began in the right cheek, subsequently involving 
the left; perforation occurred in both cheeks, and before death a large 
part of the face was gangrenous. The odor from a severe case is very 
offensive, and, in spite of all efforts at disinfection, it may fill the ward 
or even the house. Pain is rarely severe, and in many cases it is ab- 
sent. Extensive hemorrhages are rare. 

We have notes of seven cases in which noma affected the ear, being 
preceded by chronic otitis media in every instance. The disease began 
in the deeper structures of the canal, the first symptom noticed usually 



GANGRENOUS STOMATITIS— NOMA 287 

being a nodular swelling just beneath the ear, crowding the lobe upward. 
Shortly afterward there appeared the dirty brown discharge with a gan- 
grenous odor. Later, the gangrenous circle surrounded the meatus, 
which gradually extended, until in some cases the whole side of the face 
and head were involved. A probe could readily be passed into the cra- 
nial cavity. All these cases ended fatally. 

The usual duration of the disease is from five to ten days. If 
recovery takes place, there is first seen a line of demarcation; then the 
slough is thrown off, and granulation and cicatrization begin, but require 
a long time, usually leaving an unsightly deformity. 

The prognosis is grave, fully three-fourths of the cases proving fatal. 
The results depend not only upon the disease itself, but upon the con- 
dition of the patient with which it is associated. 

Gangrenous stomatitis can hardly be mistaken for any other form of 
disease occurring in the mouth, and early recognition is of great impor- 
tance, since only early treatment is likely to be successful. 

Treatment. — Much can be done to prevent the disease by careful 
attention to all the milder forms of stomatitis, particularly to the ulcera- 
tive variety. Frequent and thorough cleansing of the mouth in all acute 
infectious diseases is a part of the treatment which is too often neglected. 
This should be a matter of routine in every severe illness in a young 
child. Eecognizing the malignant nature of gangrenous stomatitis, its 
treatment should be radical from the very outset. Of the measures 
which have been proposed, that which seems to offer the best chance of 
arresting the process is excision with cauterization. This should be 
done under anesthesia. In excising, one should go some distance into 
tissues apparently healthy, for the reason that the process has always 
advanced farther in the subcutaneous tissues than in the skin. The 
edges of the wound should then be thoroughly cauterized, best by the 
Paquelin cautery. Of the other means employed, the use of strong car- 
bolic acid immediately followed by alcohol is probably the best. This is 
to be used after excising or curetting the necrotic tissue. The mouth 
should be kept as clean as possible by the use of peroxid of hydrogen. 
The general treatment should be supporting and stimulating. As the 
possibility of contagion exists, every case should be isolated. 



288 DISEASES OF THE DIGESTIVE SYSTEM 

CHAPTER II 

DISEASES OF THE PHARYNX 

ACUTE PHARYNGITIS 

Acute pharyngitis may exist as a primary disease, or with any of the 
infectious diseases, particularly searlet fever, measles, diphtheria, or 
influenza. Secondary pharyngitis will he considered in connection with 
these different diseases. 

Certain children have a constitutional predisposition to attacks of 
acute pharyngitis, and contract it upon the slightest provocation. In 
some of them there is a strongly marked rheumatic diathesis. Attacks 
of acute pharyngitis often follow exposure. In many cases they are 
associated with acute disturbances of digestion. All of the above causes 
probably act by producing local and general conditions favorable to 
the development of microorganisms already present in the mouth. The 
bacteria most frequently associated with severe attacks are the staphylo- 
coccus, the pneumococcus, the streptococcus, and less frequently, the 
influenza bacillus. 

In acute catarrhal pharyngitis the inflammation may involve the en- 
tire mucous membrane of the tonsils, fauces, uvula, posterior and lateral 
pharyngeal walls, or any part of it. It may exist alone, or in connection 
with a similar inflammation in the rhinopharynx or in the larynx. In 
the beginning there is seen an acute redness, usually involving the entire 
pharynx. This may entirely subside after twenty-four hours, or it may 
be followed by the usual changes of acute catarrhal inflammation — 
dryness, swelling, and edema. Later there is increased secretion of 
mucus, and finally there may be muco-pus. Occasionally slight hemor- 
rhages are present. 

There is pain at the angle of the jaws, which is increased by swallow- 
ing, also a sensation of dryness and roughness in the pharynx, and often 
an irritating cough. There may be slight swelling of the neighboring 
lymphatic glands. The constitutional symptoms in young children are 
often severe. Not infrequently there is a sudden onset with vomiting, 
and a rise of temperature to 102° or even 101° F. These symptoms are 
usually of short, duration, frequently less than twenty-four hours, and in 
two or three days the patient may be entirely well. In other cases the 
pharyngitis may he accompanied or followed by laryngitis. 

Acute primary pharyngitis is to be distinguished from scarlet fever, 
diphtheria, measles, and influenza. A positive diagnosis from scarlet 
fever Is impossible until a sufficient time has elapsed for the eruption to, 



ELONGATED UVULA 289 

appear, and the patient should be closely watched for the first sign of 
this. If scarlet fever is prevalent, a child with the symptoms of severe 
pharyngitis should at once be isolated while waiting for the diagnosis 
to be settled. There is commonly less difficulty in excluding measles 
because of the absence of Ivoplik's sign on the buccal mucous membrane, 
and of the accompanying catarrh of the eyes and nose. Catarrhal diph- 
theria can be excluded only by culture. 

The first step in the treatment of acute pharyngitis is to open the 
bowels freely by means of calomel, castor oil, or magnesia. The child 
should be kept in bed, and the diet should be fluid, or, in the case of 
infants, the amount of food should be much reduced. Pieces of ice may 
be swallowed frequently for the relief of pain and thirst. Internally 
there may be given two grains of phenacetin every four hours to a child 
of three years. It is important at the outset to induce free perspiration. 
The disease is not serious, and the indications are to make the child as 
comfortable as possible during the short attack. 



UVULITIS 

Acute inflammation of the uvula, with swelling and edema, occurs 
as a part of the lesion in acute pharyngitis. In rare instances the uvula 
may be the principal or the only seat of inflammation. Huber (Xew 
York) has reported two cases, one of which is unique. An infant ten 
months old was apparently well until two hours before he was seen, when 
there was noticed a constant irritating cough, accompanied by consider- 
able gagging. Later there could be seen in the mouth a prominent red 
mass, the enlarged and elongated uvula. There were also paroxysms 
of coughing, which interfered both with nursing and deglutition. The 
general symptoms were quite alarming. The uvula was found to be 
fully one inch long and half an inch wide, red and edematous; in other 
respects the throat was normal. The symptoms were relieved by multiple 
needle punctures and the use of ice. In such conditions the greatest 
relief is often afforded by the application of epinephrin or its use as a 
spray or gargle. 

ELONGATED UVULA 

Probably this is primarily a congenital condition. It is increased by 
repeated attacks of acute or subacute inflammation. The degree of 
elongation varies in different cases; in some it may be an inch in 
length. Only the mucous membrane is involved in the elongation. The 
symptoms are those of local irritation, especially a cough upon lying 



290 DISEASES OF THE DIGESTIVE SYSTEM 

down, and the sensation of a foreign body in the pharynx. In some 
cases it may be a reflex cause of asthma, or, more frequently, of catarrhal 
spasm of the larynx. The diagnosis is very easily made by inspecting 
the throat. The treatment consists in grasping the tip of the uvula with 
forceps and cutting off the excess with the scissors, or a uvulotome. 
Care should be taken not to cut off too much of the uvula, or severe 
hemorrhage may occur. 



RETROPHARYNGEAL ABSCESS 

Two distinct varieties are seen: (1) The so-called idiopathic abscesses 
which belong to infancy, and (2) abscesses secondary to caries of the 
cervical vertebrae. 

Retropharyngeal Abscess of Infancy. — All of the later investigations 
regarding this disease indicate that primarily it is not a cellulitis, but 
a suppurative inflammation of the lymph nodes (lymphatic glands) 
with a surrounding cellulitis. The retropharyngeal lymph nodes form a 
chain on either side of the median line between the pharyngeal and the 
prevertebral muscles. These nodes are said to undergo atrophy after 
the third year, and in some cases to disappear entirely. Retropharyngeal 
abscess — or, more properly, retropharyngeal lymphadenitis, since the 
process does not invariably go on to suppuration — is probably never 
primary, but secondary to infectious catarrhs of the pharynx, and is set 
up by the entrance of pyogenic bacteria, usually the staphylococcus or 
streptococcus. Its pathology is the same as the more frequent suppura- 
tive inflammation of the external cervical lymph nodes, with which 
it is sometimes associated. Usually only a single node is involved, but 
sometimes two or three are affected, and these may be situated upon 
opposite sides. We have frequently seen retropharyngeal lymphadenitis 
so severe as to give rise to marked local symptoms, although it did not 
go on to suppuration. Kormaim's observations, however, show that 
swelling of these glands in diseases of the mouth and throat is very 
much more common than is generally supposed. Similar abscesses from 
suppurative inflammation of other lymph nodes in the neighborhood 
of the pharynx may occur. We have seen one situated between the 
epiglottis and the base of the tongue. 

Etiology. — These cases almost invariably occur in infancy. Fully 
three-fourths of those that have come under our observation have been in 
patients under one year. Bokai (Buda-Pesth) reports that of sixty cases 
observed, forty-two occurred during the first year, eleven during the 
second year, and only seven at a later period. The primary disease is 
usually a severe rhinopharyngitis, or an attack of epidemic catarrh, 



RETROPHARYNGEAL ABSCESS 291 

but rarely it occurs as a sequel of scarlet fever or measles. In six hun- 
dred and sixty-four cases of scarlet fever, Bokai noted retropharyngeal 
abscess- in seven cases. After measles it is even more rare. Retro- 
pharyngeal abscess usually occurs in winter or spring, on account of the 
prevalence of the diseases upon which it depends. It is seen quite as 
frequently in children who were previously robust as in those who are 
delicate, but is more common in those who are prone to severe catarrhal 
affections. 

Symptoms. — The early symptoms in most cases are merely those of 
an ordinary rhinopharyngeal catarrh. After this has subsided the tem- 
perature may remain slightly elevated, often for a week or more, before 
local symptoms are noticeable. Sometimes, without any distinct history 
of previous catarrh, there are seen quite high temperature, from 102° to 
104° F., loss of flesh, and prostration. A careful examination may be 
required, and sometimes observations for a day or two, before the ex- 
planation of these constitutional symptoms is discovered. In other cases 
the early constitutional symptoms are so slight as to escape notice, and 
the local symptoms are the only ones present. Although usually these 
are not severe, retropharyngeal abscess may cause dyspnea, which in a 
short time assumes an alarming character. The duration of the inflam- 
matory process before abscess forms is generally five or six days, but it 
may be several weeks. The temperature is invariably elevated, usually 
from 100° to 103° ¥.; occasionally it may be 104° or 105° F., with 
symptoms of prostration seemingly out of all proportion to the local 
disease, but which are to be explained by the tender age and feeble 
resistance of the patient. 

The most characteristic local symptoms are the posture, the head 
being drawn far backward to relieve pressure on the larynx, the noisy 
respiration with the mouth open, difficulty in deglutition and some 
external swelling. Sometimes the first thing to attract notice is a sudden 
attack of dyspnea severe enough to cause asphyxia. This is due to the 
pressure forward of the abscess encroaching upon the larynx. The mouth 
may be dry, or there may be a copious secretion of pharyngeal mucus. 
The dyspnea is in most cases greater on inspiration, and in some it is 
noticed only then, expiration being normal. The difficulty in swallowing 
is greater when the tumor is low. The child may find it impossible to 
swallow, and in consequence may refuse to nurse; or the difficulty in 
nursing may depend upon the nasal obstruction. Sometimes there is 
regurgitation of food through the nose or mouth. The voice is usually 
nasal. Generally there is no hoarseness, but a peculiar short cry which 
is quite characteristic. There may be, although rarely, aphonia. Usually 
there is some swelling to be seen externally, just below the angle of the 
jaw in front of the sternomastoid muscle; exceptionally this may be 



292 DISEASES OF THE DIGESTIVE SYSTEM 

more prominent than the internal swelling. Occasionally torticollis is 
an early symptom. 

On inspection of the throat there is seen a distinct bulging -of the 
lateral wall of the pharynx, usually a little above the base of the tongue. 
The swelling may be so great as to crowd the uvula to one side and 
nearly fill the pharynx. It is rarely, if ever, in the median line. There 
is usually redness of the mucous membrane and edema of the uvula and 
of the adjacent parts. On digital examination the swelling is made out 
even better than by inspection. It may be situated so low down as not 
to be visible at all. In the early stage there may be felt only a localized 
induration or a somewhat diffuse swelling, but by the time the swelling 
is large enough to produce marked symptoms, fluctuation can generally 
be discovered. 

Prognosis. — When left to itself the abscess may open into the pharynx, 
the pus being swallowed or expectorated. The cavity may close rapidly 
by granulation, and in a few days the patient be entirely well; or the 
abscess may refill. External opening almost never takes place. It is 
rare for much burrowing to occur. In young or very delicate infants 
the constitutional symptoms may be so. severe that the child continues 
to fail even after the evacuation of the abscess, and dies usually from 
-^bronchopneumonia. 

Death may occur from asphyxia due to pressure upon the larynx, 
to edema of the glottis, or from rupture of the abscess into the air 
passages, especially if this occurs during sleep. Carmichael, Bokai, and 
others have reported deaths from ulceration into the carotid artery, or 
one of its large branches. Carmichael's patient was only five weeks old. 
The general mortality is from five to ten per cent; many deaths are 
due to a failure to make the diagnosis. Gautier has collected ninety- 
five cases, with forty-one deaths. In our experience death has most fre- 
quently resulted from late bronchopneumonia; in one case it was due 
to a secondary retro-esophageal abscess. 

Diagnosis. — Eetropharyngeal abscess is to be suspected if in an infant 
there is difficulty in swallowing, noisy dyspnea, mouth-breathing, and 
the head drawn backward. A positive diagnosis is possible only by a 
digital examination of the pharynx. The mistake most often made is, 
that the physician, called to a young child suffering from great dyspnea, 
has .jumped at a diagnosis of laryngeal stenosis, and forthwith performed 
tracheotomy or intubation, without taking the trouble to get the history 
or to make a careful examination of the pharynx. Many such cases 
are reported in which the child has died during the operation or imme- 
diately afterward, the autopsy first revealing the nature of the disease. 
A sudden attack of dyspnea like that caused by the rupture of an abscess 
might be produced by the lodgment of a foreign body in the pharynx 



RETROPHARYNGEAL ABSCESS 293 

or larynx. A digital examination would aid in the diagnosis. We once 
saw in an infant a sarcoma of the pharyngeal lymph nodes which gave 
an external and internal tumor exactly like that of a retropharyngeal 
abscess. 

Treatment. — Before the abscess has pointed, hot applications may be 
made to the throat to relieve the symptoms and to hasten the formation 
of pus, since resolution is not to be expected. Spontaneous opening 
should never be waited for, on account of the danger of the rapid develop- 
ment of serious symptoms from pressure or edema, or of suffocation 
from an opening into the air passages, especially during sleep. 

As soon as the diagnosis is made the case should be carefully watched, 
and as soon as a point of superficial fluctuation is detected, but not be- 
fore, the pus should be evacuated. External incision has been advocated, 
but the internal opening is much to be preferred. In opening through 
the mouth the patient should be seated in an upright position and the 
head firmly held. The use of a mouth-gag may cause asphyxia. The 
abscess may be opened with a bistoury which has been guarded to its 
point by winding with rubber plaster, or better with a pair of blunt 
pointed scissors or with an artery clamp. Often a finger-nail sharpened 
to a point is all that is necessary. After opening it is well to insert the 
finger into the cavity to enlarge the opening and break down any septa ; 
for after a simple puncture the abscess may refill. The head should then 
be bent forward, to allow the pus to escape through the mouth. The 
amount of pus evacuated varies from one dram to half an ounce. In 
the majority of cases no after-treatment is required. The relief of the 
dyspnea and dysphagia is immediate, and, except in young infants, 
recovery usually rapid. Occasionally there is so much edema that even 
after evacuation tracheotomy may be necessary. 

Retropharyngeal Abscess from Pott's Disease. — This form is rare in 
comparison with that just described, and under three years of age it is 
extremely so. These abscesses are usually larger, and the amount of 
pus contained may be from four to eight ounces. They form very much 
more slowly, often lasting for months, and as with other secondary 
abscesses, the constitutional symptoms are seldom severe. The swelling 
is frequently in the median line, and is not so circumscribed as in the 
idiopathic cases. The pus often burrows along the spine for several 
inches. 

The symptoms of Pott's disease of the cervical region are usually 
present for several months before the appearance of the abscess. Some- 
times the abscess precedes the deformity, and it may be the first intima- 
tion of the existence of bone disease. The local symptoms resemble 
those of the idiopathic cases, but they develop more slowly, and sudden 
attacks of fatal asphyxia are very rare. External swelling is usually 



294 DISEASES OF THE DIGESTIVE SYSTEM 

seen, and it may be quite large, extending almost from one ear to the 
other, forming a distinct collar. On digital exploration there may be 
found an irregularity of the anterior surface of the cervical vertebrae, 
and occasionally a marked angular prominence. 

When left to themselves these abscesses may open externally in front 
of the sternomastoid muscle just below the jaw, sometimes nearly as low 
as the clavicle; they may rupture internally into the pharynx, the 
esophagus, or the air passages; or they may burrow a long distance in 
front of the spine. Death may result from pressure upon the larynx, 
or from rupture into the larynx, trachea, or pleura; all these, however, 
are rare. The abscesses not infrequently refill after they are evacuated, 
and occasionally a discharging sinus is left for many months. 

Treatment. — These abscesses should be opened or aspirated as soon as 
they are large enough to give rise to local symptoms. The external 
incision just in front of the sternomastoid muscle is generally to be pre- 
ferred to opening through the mouth, since it gives better drainage, and 
the after-treatment is more easily carried on ; and a sinus opening exter- 
nally is less objectionable than one opening into the pharynx. 



ADENOID GROWTHS OF THE VAULT OF THE PHARYNX 

This is a very common condition and one formerly much neglected by 
the general practitioner. It is the source of more discomfort and the 
origin of more minor ailments than almost any other pathological condi- 
tion of childhood. 

There is a mass of lymphoid tissue situated at the vault of the phar- 
ynx which in structure closely resembles the tonsils. It is often spoken 
of as the "pharyngeal tonsil." Like the faucial tonsils, this may become 
greatly hypertrophied, so as to form a tumor large enough to fill the 
rhinopharynx completely. Those tumors have a broad attachment 
which is sometimes more to the roof, and sometimes more to the pos- 
terior wall of the pharynx. The term adenoid vegetations was given 
to them by Meyer, who first described them in 1868. In infancy these 
growths are soft, vascular, and spongy; in older children they become 
firm, dense, and more fibrous. Their appearance is well shown in Fig. 
29. Adenoid vegetations are associated with hypertrophy of the faucial 
tonsils in about one-third of the cases. Growths large enough to cause 
decided nasal obstruction may in time produce changes in the facial 
bones amounting to positive deformity. The bony palate may be dome- 
shaped or even acutely arched; the dental arch of the upper jaw be- 
comes almost V-shaped. Deformities of the thorax also occur, which will 
be described with the symptoms. 



ADENOID GROWTHS 



295 



Etiology. — Hereditary influences certainly play some part in the 
production of this condition. Frequently every one of a large family 
of children may be affected, and often the parents have suffered from 
the same condition. While infants are born with adenoid tissue in the 
nasopharynx, it is in almost all instances small in amount and seldom 
increases markedly in size until after several months. What causes the 




Fig. 29. — Adenoid Vegetations, Natural Size. (1) From child eight months old; 
(2) from child twenty-two months old; (3) from child two and one-half years old; 
(4) from child two and one-half years old; (5) from child three years old. With the 
exception of (5) all were removed with a single sweep of the curette. Although the 
growths represented are somewhat larger than the average for the ages mentioned, 
just such ones are constantly met with in practice. 



abnormal development of this tissue it is hard to say. Adenoid growths 
are most common in damp, changeable climates. Their first symptoms 
often follow an attack of measles, scarlet fever or diphtheria. The 
repeated attacks of rhinopharyngitis associated with adenoid growths are 
more often a result than a cause of the condition. 

Czerny believes that the excessive growth of tissue in the rhino- 
pharynx is in many instances the result of overfeeding. It is certainly 
true that adenoid growths are much more common in well nourished 
than in poorly nourished children. Much interest has lately been awak- 
ened regarding the relation of adenoid growths to tuberculosis. Of 
945 cases collected by Lewin in which specimens of adenoids were ex- 



296 DISEASES OF THE DIGESTIVE SYSTEM 

a mined, tuberculosis was present in five per cent. Though this propor- 
tion is do doubt much higher than will be found in private practice, 
the fact is an important one; for it is highly probable that this is the 
channel of infection in not a few cases of tuberculosis. 

Symptoms. — The symptoms of adenoid growths are usually first no- 
ticed when children are from eighteen months to three years old; but 
they may be present almost from birth. We have in several instances seen 
i Ik in to a marked degree in infants only a few months old. The symp- 
toms generally increase in severity as age advances, being always better. 
in summer and worse in winter, until the age of six or seven is reached. 
The chief symptoms are those which relate to (1) chronic rhinopharyn- 
geal catarrh, (2) mechanical obstruction, (3) otitis and other aural 
conditions, (4) general malnutrition and anemia, (5) reflex nervous 
phenomena. 

The rhinopharyngeal catarrh shows itself by a persistent nasal dis- 
charge, or frequently recurring acute attacks of head-colds during the 
m inter season. In susceptible children these attacks are often the begin- 
ning of a bronchitis, which may keep a young child indoors almost the 
entire winter. 

The obstructive symptoms are inability to blow the nose, mouth- 
breathing constantly or only during sleep, and a nasal voice. The 
difficulty in breathing is increased when the child lies upon the back. 
In consequence of this, children sleep in all sorts of positions — lying 
upon the face, sometimes upon the hands and knees, and often toss rest- 
lessly about the crib in the vain endeavor to find some position in which 
respiration is easy. The attacks of dyspnea at night may amount almost 
to asphyxia, and are the explanation of many of the so-called night- 
terrors from which children suffer. When the obstruction has existed 
from infancy there are often deformities of the chest; these are most 
marked in rachitic subjects. The most frequent one consists in deep 
lateral depressions of the lower part of the chest, with a prominence 
of the sternum. The deformity is due to interference with pulmonary 
expansion. There is often seen a flattening at the root of the nose, and 
sometimes a prominence of the transverse vein in this region. 

Some impairment of hearing exists in a large proportion of the cases. 
Blake (Boston) found this to be true in 39 out of 47 cases examined; 
in 35 of these marked improvement in the hearing followed removal 
of the adenoid growths. Deafness may be due to tubal catarrh or to 
oiiiis. Often a, history is given of several attacks of suppurative otitis. 

Many young children who are subject to attacks of spasmodic croup 
have adenoid growths, the removal of which is frequently followed by 
I he complete cessation of such attacks. Other respiratory symptoms 
associated with adenoid growths are intractable cough without bronchial 



ADENOID GROWTHS 297 

symptoms or signs, and persistent hoarseness lasting for months, or even 
for years and recurring every cold season. These symptoms are the result 
of the chronic inflammation in the rhinopharynx, sometimes extending 
to the larynx, with an increased secretion of thick mucus. Both these 
conditions are often cured by the removal of the adenoid growths after 
all other treatment has been without effect. Bronchial asthma seems 
at times to be dependent upon these growths. 

The reflex symptoms ascribed to adenoid growths have been greatly 
exaggerated. Children become nervous if they have obstructive symp- 
toms with disturbed sleep, or if they spend much of the time in bed or in 
the house. Such children present a number of nervous manifestations 
that may be due to other factors producing nervousness, quite as much 
as to adenoid growths. Incontinence of urine is very rarely cured by the 
removal of such growths. Headaches with them are, however, common. 
Stammering, chorea and even epileptiform seizures have been attributed 
to adenoid growths, but without sufficient justification. 

The general health of patients suffering from adenoid growths may 
be impaired from loss of sleep and from confinement to the house neces- 
sitated by attacks of bronchitis or rhinopharyngitis. Anemia is often 
present. In old cases of a severe character, children may have a dull 
and stupid facial expression. They are languid, listless, often depressed 
and this associated with deafness frequently causes them to be regarded 
in school as children who are somewhat deficient mentally. 

These patients are always better in summer and worse in winter. 
The natural course of the growths if left to themselves is to increase up 
to a certain point, and then to remain stationary until puberty, when 
they usually undergo some degree of atrophy. This, with the marked 
increase in the capacity of the rhinopharynx which occurs at this time, 
results in a disappearance of the most aggravated symptoms. The re- 
moval of the patient to an elevated region with a dry atmosphere will 
often result in a relief from all the symptoms, and a diminution in the 
size of the growth, but unless such a change in residence is permanent 
the symptoms are liable to return. Under ordinary conditions there 
is little or no tendency to spontaneous recovery. In children with 
adenoid growths attacks of diphtheria, scarlet fever, measles, and whoop- 
ing-cough are all likely to be more severe. 

Diagnosis. — In a well-marked case the condition is usually evident 
from the history, and can scarcely be overlooked. The intractable nasal 
catarrh, upon which no treatment, local or general, has more than a tem- 
porary influence, the mouth-breathing, the disturbed sleep, and the slight 
deafness — all are characteristic. At other times the patients come for 
treatment on account of the general symptoms — the nervous depression, 
the headaches, or the anemia. In rare cases the leading symptom may 



298 DISEASES OF THE DIGESTIVE SYSTEM 

be epistaxis. The symptoms do not always depend upon the size of the 
growth, for in a small throat quite a small growth may cause very marked 
symptoms. 

Although the history is in most cases clear, only an examination can 
make us certain that an adenoid growth exists. The growth is ordinarily 
felt as an irregular, granular, soft, velvety mass, or sometimes as a firm 
tumor completely blocking the passage; and the finger, when withdrawn, 
is frequently covered with blood. By posterior rhinoscopy, the growth 
in older children can be seen. 

Treatment. — The disappearance of adenoid growths is possible only 
when they are small. This is aided by removal to a warm, dry climate 
for the winter season. All possible means should be employed to prevent 
these patients from taking cold. With the larger growths these methods 
may improve the catarrhal symptoms, but can hardly affect the obstruc- 
tive ones. The reduction of tumors of any considerable size by local 
applications is a delusion ; every marked case that has come to our notice 
has been relieved only by operation. 

Removal of adenoid growths is indicated : ( 1 ) When the obstructive 
symptoms — habitual mouth-breathing, disturbed sleep, nasal voice, chest 
deformities, etc. — are marked; (2) for a chronic nasal discharge, con- 
stantly recurring attacks of rhinopharyngitis, particularly when these 
tend to develop into bronchitis or laryngitis; (3) when there is asthma 
or repeated attacks of catarrhal spasm of the larynx; (4) with deafness, 
chronic otitis, or repeated attacks of acute otitis. Although striking 
improvement is not infrequent, one should be cautious about promising 
too much from operation, especially as regards the nervous conditions; 
also in older children when there "is deafness or asthma. 

The preferable time for operation is the late spring or early summer, 
in order that during the warm months the mucous membranes may have 
an opportunity to regain their normal condition; however, operation 
may be done at any time except during attacks of acute catarrh. Unless 
the symptoms are very marked, it is desirable to defer operation until 
a child is at least two years old. 

Removal of adenoids by scraping with the finger nail is at best a very 
uncertain method, and is not to be advised. Operation for the removal 
of* adenoids is preferably done with general anesthesia. So many 
deaths from operations done under chloroform have now been reported, 
and so many darrow escapes have occurred that have not been reported, 
that chloroform anesthesia should be given up altogether. Deep anes- 
thesia is not usually necessary, and if the semi-erect position is assumed 
il increases the danger of the entrance of blood or portions of the growth 
into the larynx, which might cause asphyxia. The operation should only 
he dune by one skilled in its performance. 



ADENOID GROWTHS 299 

Hemorrhage is always abundant, and seems alarming to one who 
sees it for the first time, but it generally ceases in a few minutes. 
There is evidence that the administration of fifteen or twenty grains 
of calcium lactate during the twenty-four hours preceding the opera- 
tion materially lessens the bleeding. A child should not pass from 
the physician's observation until all hemorrhage has stopped. He 
should be kept quiet, preferably in bed, for twenty-four hours; and in 
the house for five or six days, unless the weather is warm. No after- 
treatment is necessary. Eecurrences are occasionally seen even after a 
thorough operation by an experienced surgeon; but many of them are 
due to the fact that the primary operation was incomplete. The im- 
provement generally begins in a few days, sometimes at once, though 
the full benefit may not be seen for a month. The breathing becomes 
freer, the sleep more quiet; the mouth may soon be habitually closed; 
voice and hearing improve, and the benefit to the general health is soon 
apparent. The pallor, listlessness, and inattention disappear, and a 
rapid increase in weight often follows. The entire appearance of the 
child may in a few months be transformed. 

Dangers and Accidents from Operation. — While it is rare that any 
accidents of a serious nature are met with, it should not be forgotten 
that they may occur. Undue laceration of the parts may result from a 
bungling operation, particularly with too large curettes or with the for- 
"ceps. Hemorrhage may be excessive or even fatal. We have seen but 
one case of fatal hemorrhage, this in a bleeder, and but two other in- 
stances of serious hemorrhage. A fatal result is exceedingly rare. 
Hemorrhage may be continuous after operation, or secondary, in which 
case it almost invariably occurs within twenty-four hours. It is impor- 
tant, therefore, that the patient be kept under observation for that time. 
Bleeding is best controlled by injecting into the rhinopharynx through 
the nostrils one or two drams of hydrogen peroxid, full strength, or, 
this failing, a solution of epinephrin (1-1000) may be used in the same 
manner. If this is not effective, plugging of the rhinopharynx and 
posterior nares may be resorted to. In all cases the patient should be 
kept absolutely quiet. 

Occasionally an acute attack of bronchitis or otitis occurs after opera- 
tion; and in a few recorded instances acute meningitis has followed. 
The danger of asphyxia from the entrance of blood or the tumor into 
the larynx has already been mentioned. 

The danger from chloroform anesthesia is due not so much to the 
nature of the operation as to the condition of the patient. It is now 
well established that all children in whom the condition known as status 
lymphaticus is present, bear chloroform very badly. 



./ 



V 



00 DISEASES OF THE DIGESTIVE SYSTEM 



CHAPTEE III 
DISEASES OF THE TONSILS 

The tonsils are lymphoid structures closely resembling Peyers 
patches, but, instead of having a flattened surface, the lymphoid tissue in 
the tonsils is folded upon itself, forming quite deep depressions — the ton- 
si liar crypts. These crypts, like the surface of the tonsils, are lined by 
epithelial cells. They contain lymphoid cells, desquamated epithelium, 
particles of food, and bacteria. Under normal conditions the tonsils 
take no part in absorption from the mouth. When, however, their epi- 
thelium is diseased or removed, the tonsils absorb with very great facil- 
ity every sort of poison which the mouth may contain. 

The most important chronic infection which takes place through 
the tonsils is that of tuberculosis; the most important acute or sub- 
acute infection is probably that of pyogenic organisms. Poisons absorbed 
by the tonsils are taken up by the lymphatic vessels and through them 
reach the cervical lymph nodes and finally may be carried into the gen- 
eral circulation. 

Acute inflammation of the tonsils, like that of the pharynx, occurs 
regularly in diphtheria, scarlet fever, and measles, less frequently in the 
other infectious diseases. The secondary forms will be considered with 
the diseases with which they are associated. 

Acute catarrhal tonsillitis, or inflammation of the mucous membrane 
covering the tonsils, occurs as part of the lesion in acute pharyngitis, 
but very rarely is seen alone. 



MEMBRANOUS TONSILLITIS 

(Pseudodiphtheria ; Streptococcus Angina; Croupous Tonsillitis; Septic Sore 

Throat) 

This occurs both as a primary inflammation and secondary to the 
acute infectious diseases, especially scarlet fever and measles. The an- 
gina of scarlet fever is essentially a part of that disease and is more 
fully considered in connection with it. 

Etiology. — As was first shown by Prudden in 1888, and abundantly 
confirmed by others since that time, this inflammation is usually due to 
the streptococcus; it may be found alone, or associated with the staphy- 
lococcus aureus, and occasionally the staphylococcus may be found alone. 

The streptococcus is very frequently found in the throats of healthy 



MEMBRANOUS TONSILLITIS 301 

children, particularly in winter and in cities, and more often in those 
live in tenements or who are inmates of hospitals or other institu- 
tions. The local conditions in the mucous membranes during an attack 
of measles, scarlet fever, and other infectious diseases, are especially 
favorable for the development of these germs, which at such times are 
very often present in great numbers even when no membrane is seen. 
There are seen occasionally, especially in cities, epidemics of great 
severity in which many persons, adults as well as children, but the latter 
chiefly, are attacked. Such epidemics have in recent years broken out in 
Boston, Chicago and Baltimore. Several of these have been carefully 
studied epidemiologically and have been traced to the milk supply. The 
milk has been infected from one or more cows suffering from septic 
infection of the udder. The organism has been found to be a hemolytic 
streptococcus with rather distinct cultural characteristics. 

In the presence of an epidemic of severe tonsillitis, the milk supply 
should always be suspected. 

Lesions. — In the primary cases the membrane is generally confined 
to the tonsils or is chiefly there, only small deposits appearing elsewhere. 
In the secondary cases, the entire pharynx may be covered and the disease 
may extend to the nose, the mouth, the middle ear, and rarely to the 
larynx, trachea, and bronchi. 

The structure of the membrane resembles that of true diphtheria, 
and it may be impossible by a microscopical examination to separate the 
two diseases. 

In the mild cases the inflammation of the mucous membrane is a 
superficial one and the pseudomembrane is not very adherent. In the 
severe cases, chiefly the secondary ones, the process extends much deeper. 
Besides the pseudomembrane upon the surface, there is intense con- 
gestion, edema, and cell-infiltration of all the lymphoid and cellular 
tissue of the pharynx. It may involve the tonsils, soft palate, uvula, epi- 
glottis, adenoid tissue of the vault and the entire pharyngeal ring, and 
also extend to the external lymph nodes and surrounding cellular tissue. 
The process both in the throat and externally in the neck may terminate 
in resolution, suppuration, or in necrosis. In severe cases, especially in 
the epidemic form, there are found the lesions of general septicemia 
or pyemia. There may be peritonitis, endocarditis, pericarditis, menin- 
gitis, arthritis and erysipelas. 

The streptococci are found in the false membrane, in the underlying 
mucous membrane, in the lymph spaces, in the lymph nodes, and in the 
visceral lesions. 

Symptoms. — 1. The Primary Cases. — The onset is usually abrupt, 
with well-marked symptoms: there are frequently chilly sensations, head- 
ache, vomiting, general pains, and in most cases the child complains of 






302 DISEASES OF THE DIGESTIVE SYSTEM 

soreness of the throat and pain on swallowing. There are first seen a 
general redness and swelling of the tonsils, sometimes of the entire 
pharynx; shortly afterward membranous patches appear upon the ton- 
sils. These vary greatly in appearance. In color they are yellow or 
gray, often changing later to a dirty olive tint. The membrane seems 
loosely attached and can frequently be wiped off with a swab. It is 
often irregular in its outline, which is not sharply defined. The mem- 
brane usually remains but three or four days and disappears rapidly. 
As a rule, it is limited to the tonsils, and does not spread after it first 
forms. Occasionally, however, small patches are also seen upon the 
fauces or the pharynx. The constitutional symptoms are generally 
severe during the first two days, and the temperature may be 103° or 
10-±° F., but by the third day it falls, and most of the symptoms subside. 
It is rare for the disease to extend either to the nose or the larynx. 

The epidemic cases are usually more severe and the course prolonged. 
After the first few days, the throat symptoms may nearly disappear, but 
the fever continues at times for many weeks. The enlargement of the 
cervical glands is a striking feature, especially of those cases that recover, 
and this enlargement may persist for a considerable time after the 
establishment of convalescence. Suppuration of the glands is infre- 
quent. Eruptions are quite common. They may be small, punctate 
and hemorrhagic or erythematous. If of the latter type, they may be 
mild or intense, at times closely simulating scarlet fever. 

The tendency to complications is great. One of the most common 
is peritonitis, which is almost uniformly fatal. Endocarditis and peri- 
carditis are frequently seen. There may be septic arthritis, erysipelas 
or localized abscesses. Otitis media is often associated. Death may be 
• liic to the complications or to the septicemia. It is a very severe form 
of disease. Except in the epidemic cases, the complications and sequelae 
are infrequent. 

2. The Secondary Cases. — Some of these are mild, but the majority 
are severe. The clinical picture of the latter is that of scarlatina angi- 
nosdj as given by the older writers. 

In measles the throat symptoms are somewhat later than in scarlet 
fever ; they may begin at the height of the primary fever, and increase 
while the eruption fades. The process is almost invariably compli- 
cated by bronchopneumonia. 

Secondary cases as a class arc characterized by high temperature 
(Fig. .')()), rapid, feeble pulse, great prostration, delirium, apathy or 
stupor, and often albuminuria. In fatal cases death usually occurs 
;it the height of the disease, from asthenia, bronchopneumonia, or nephri- 
tis. If none of these complications develop, patients may withstand the 
toxic symptoms even when they are very severe. 



MEMBRANOUS TONSILLITIS 



303 



There may be in connection with the local process in the throat, deep 
sloughing of the tonsils or adjacent structures, suppuration of the lym- 
phatic glands or in the cellular tissue of the neck, occasionally followed 
by serious hemorrhage. However, these complications are rare, and if 
the patient survives the danger of the acute stage of the disease, he 
usually recovers. 

Diagnosis. — The clinical features which distinguish membranous ton- 
sillitis from diphtheria are considered under the latter disease. It is 



DAY 


1 


2 


3 


4 


5 


c 


7 


8 


9 


10 


11 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 


22 


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e 


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106° 
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Fig. 30. — Streptococcus Angina, following Measles. The chart begins at the time 
of the full eruption in a severe case of measles. On the third day the temperature 
fell, with fading eruption, and child seemed convalescent. With secondary rise in 
temperature, the tonsils, which before had been only red, showed membranous 
patches, the exudation rapidly spreading until the entire pharynx was covered; 
throat symptoms very severe, with great swelling of cervical glands, but the mem- 
brane did not extend beyond the pharynx. From sixth to twelfth day a most pro- 
found septicemia, so that life was despaired of. The patient was a vigorous child, 
and, escaping both nephritis and pneumonia, made a good recovery. Convalescence 
quite rapid; no sequelae. Repeated cultures were made from the throat, but all 
showed only streptococci. Patient a girl four years old. Case observed in private 
practice. 



impossible in any case to be certain of the diagnosis except by cultures; 
for, although by clinical symptoms alone one may in the great majority 
of cases be certain that a given case is one of true diphtheria, to say 
that any membranous inflammation of the throat is not diphtheria is 
impossible. 

A membrane which appears in the throat early in the course of 
measles or scarlet fever, or at the height of the primary disease, is usu- 
ally due to the streptococcus; while one which develops late or after the 
primary fever has subsided, is frequently due to the diphtheria bacillus. 
When an eruption is present the diagnosis from scarlet fever may be 
very difficult, at times well nigh impossible. 

Prognosis. — In a child previously healthy, primary membranous ton- 
sillitis, except the epidemic form, is not a serious disease. In the sec- 



304 DISEASES OF THE DIGESTIVE SYSTEM 

ondary cases, we find very different conditions. From the best available 
statistics it would appear that the usual mortality, when it is secondary 
to scarlet fever and measles, is from fifteen to twenty per cent. How- 
ever, when these diseases prevail epidemically in institutions, the mor- 
tality is often higher than this. 

Treatment. — Every child with a membranous patch on the tonsils 
requires close watching; strict quarantine should be enforced until the 
diagnosis is positively settled, and even if it is not diphtheria, close 
contact with other people should be prevented. If under three years 
old, unless the case can be seen frequently, diphtheria antitoxin should 
be administered, pending the result of a bacteriological examination. 
The primary cases require only the treatment of an attack of tonsillitis. 

In the severe secondary and septic cases the nose and pharynx should 
be syringed with a warm saline solution every two hours by day and 
every four hours by night. Where the swelling and edema are great, 
benefit may result from frequent spraying with solutions containing 
epinephrm, also from inhaling hot vapor impregnated with eucalyptol, 
benzoin, etc. As an external application, whenever there is great adenitis 
and cellulitis, nothing is so beneficial as the ice-bag. 

The general management of these cases as to feeding, stimulants, 
etc., is the same as in diphtheria. Aside from stimulants no internal 
medication should be attempted with young children. Those who are 
older may take with advantage tr. ferri chlor., gtt. v to x, with glycerin, 
every three or four hours. All milk should be boiled when there is an 
outbreak of several cases of severe tonsillitis in a community or family. 



ULCEROMEMBRANOUS TONSILLITIS 

(Vincent's Angina) 

This is an inflammation somewhat resembling croupous tonsillitis, 
but it is often unilateral and associated with superficial ulceration. The 
tonsil is covered with a dirty yellowish exudation, which may be mistaken 
lor diphtheria. There is superficial necrosis, and when this tissue is 
wiped away with a swab, bleeding occurs. The disease is further dis- 
tinguished by the swollen lymph nodes at the angle of the jaw, and by 
the fact that the constitutional symptoms which accompany other forms 
of tonsillitis are either very slight or absent altogether. The etiology 
is similar to, if not identical with that of ulcerative stomatitis, with 
which it is sometimes associated. At such times the breath is foul and 
there is often profuse salivation. 

CTlcerbmembranous tonsillitis was first described by Vincent, and 



FOLLICULAR TONSILLITIS 305 

by him attributed to a fusiform bacillus which he described, although a 
spirillum was found associated with it. Vincent's observations have been 
confirmed, and it has been shown that the spirillum is a degenerative 
form of the bacillus. 1 

The chief interest in ulceromembranous tonsillitis lies in the diag- 
nosis, although it is not an infrequent disease. It is to be treated, like 
ulcerative stomatitis, by the internal administration of chlorate of pot- 
ash, combined with the local application of some antiseptic, such as 
peroxid of hydrogen or a ten-per-cent solution of nitrate of silver. 



FOLLICULAR TONSILLITIS 

This is the most frequent and most characteristic form of inflamma- 
tion of the tonsil. It is essentially an inflammation of the tonsillar 
crypts, and secondarily of the whole glandular structure. 

Etiology. — There is seen in certain children a predisposition to at- 
tacks of tonsillitis, so that from very slight exciting causes these occur — 
sometimes from exposure, sometimes possibly from derangement of the 
stomach, and sometimes without any evident reason. Children with a 
rheumatic inheritance appear to be more susceptible than others. One 
attack predisposes to a second. Patients suffering from chronic hyper- 
trophy of the tonsils are exceedingly prone to acute tonsillitis. It is not 
very common in infancy, but after this period it is very frequent through- 
out childhood. The disease, in all probability, begins as an infectious 
inflammation at the bottom of the crypts, due to the presence of strep- 
tococci or staphylococci, which readily enter from the mouth, and excite 
an attack whenever favorable conditions are present. 

Lesions. — As a result of the inflammation, the tonsillar crypts are 
filled with epithelial cells, pus cells, mucus, and bacteria. These form 
masses which appear at the mouth of the crypts as small yellow dots, 
often miscalled ulcers. Sometimes, in addition, fibrin is poured out, 
and forms, with the other inflammatory products, little plugs which 
project somewhat from the surface of the mucous membrane, and which 
can easily be pressed out. Accompanying the changes in the mucous 
membrane above mentioned, there are acute congestion and swelling of 
the whole tonsils, with more or less proliferation of the lymphoid i issue. 

1 Vincent's bacillus is about twice as long as the Klebs-Loeffler bacillus. It is 
thin, with pointed ends, and sometimes bent; it is negative to Gram's stain. The 
fusiform bacillus is occasionally found alone; the spirillum, never alone. The 
bacillus is found in smears from the affected tonsil, in making which it is recom- 
mended to go deeply into the necrotic tissue, since the superficial parts are 
crowded with other bacteria. It is grown with difficulty and only upon special 
culture media. 



306 DISEASES OF THE DIGESTIVE SYSTEM 

Follicular tonsillitis is almost always bilateral. Although the patholog- 
ical process is generally limited to the tonsils, there may be more or 
less pharyngitis associated. 

Symptoms. — The general symptoms usually appear before the local 
ones, and are often quite severe. The onset is abrupt with chilly sensa- 
tions, occasionally a distinct rigor. In infants there is often vomiting, 
and sometimes diarrhea. There is pain in the back, in the muscles of 
the extremities, and in the head. Sometimes there is pain in the lateral 
cervical muscles. The temperature rises rapidly to 102° or 103° F., 
often it touches 104° or 105° F. 

The first local symptoms are some swelling of the tonsils and the ap- 
pearance upon them of isolated yellow spots a little larger than a pin's 
head. Often these can be wiped off with a swab, or the little plugs can be 
squeezed out, leaving slight depressions. Later there is acute congestion 
of the tonsil, with more swelling. Even when the disease is at its height 
the local pain and discomfort may be only moderate, and in many cases 
scarcely noticeable. The swelling and tenderness of the lymph glands 
behind the angle of the jaw are not great, and may be absent. 

The constitutional symptoms, as a rule, last three days, and are most 
severe upon the first day. The local symptoms last somewhat longer, but 
usually by the end of the fourth clay the exudate has disappeared, 
although enlargement of the tonsil may persist for a week or even longer. 
On account of the connection of tonsillitis with rheumatism, the heart 
should be watched during attacks, especially in those who are subject 
to them. 

Diagnosis. — Tonsillitis may be confounded at its onset with scarlet 
fever. The great frequency of tonsillitis makes inspection of the throat 
imperative in every case of acute illness in children. The diagnosis from 
diphtheria is considered in connection with that disease. 

Treatment. — Follicular tonsillitis is a mild disease without danger to 
1 1 If. and one which runs a short, self-limited course. The indications 
arc, therefore, to make the patient as comfortable as possible by the 
relief of individual symptoms. Older children, particularly those who 
aiv rheumatic, should be treated with sodium salicylate, or aspirin, four 
or five grains every three hours being given for the first twenty-four 
hours, and later less frequently. To infants these drugs must be given 
in smaller doses and with care, lest they upset the stomach. The general 
muscular pains of the first day are best relieved by phenacetin, two 
-rains every lour hours to a child three years old. Later it may be 
used in smaller doses, hut enough should be given to make the patient 
comfortable. 

Local treatment is better omitted with infants. Older children may 
gargle with a solution of boric acid or may use a spray of DobelPs solu- 



PHLEGMONOUS TONSILLITIS 307 

tion. Benefit often follows painting the tonsils with tincture of iodin 
or a ten-per-cent solution of silver nitrate. In all doubtful cases the 
patient should be isolated and the same general treatment adopted as in 
diphtheria. 



PHLEGMONOUS TONSILLITIS— PERITONSILLAR ABSCESS— QUINSY 

This is an inflammation of the cellular tissue surrounding the tonsil, 
sometimes invading the tonsil itself. It may terminate in resolution, but 
usually goes on to the formation of an abscess. Phlegmonous tonsillitis 
is much less common in children than in adults, and, compared with the 
other forms, it is a rare disease in early life. It is the only variety which 
is regularly unilateral. In most cases the inflammatory process is cir- 
cumscribed, but in rare instances there is seen a diffuse phlegmonous 
inflammation of the pharynx. 

In certain patients there exists a constitutional predisposition to the 
disease, which may be associated with rheumatism. The exciting cause 
may be exposure, or anything which may reduce the patient's general 
health, to which there is added local infection. Catarrhal pharyngitis 
predisposes to this disease. 

Symptoms. — The onset resembles that of follicular tonsillitis, the 
temperature is often high, and the muscular pains and prostration severe. 
There is acute pain in the throat, which is increased by deglutition, 
and finally may be so great that swallowing is almost impossible. It is 
difficult to open the mouth. There is pain in the lateral muscles of the 
neck, and often tenderness. In the beginning but little can be seen on 
inspection, even though the patient complains of a very sore throat. This 
is always a suspicious circumstance, and should lead one to look out for 
quinsy. It is due to the fact that the inflammation begins in the deeper 
tissues, and that the mucous membrane is affected later. After twenty- 
four or forty-eight hours there is usually quite marked swelling, which 
is rather more behind the tonsil than elsewhere, pushing it upward and 
forward ; sometimes it is more in front of the tonsil. A little later there 
is intense inflammation of the mucous membrane covering the tonsil, 
fauces, and uvula, and not infrequently a fibrinous exudate; the uvula 
may be pushed to one side, and the isthmus of the fauces diminished to 
barely one-half its natural size. In one of our own cases marked tor- 
ticollis was present, and existed for two or three days before the diagnosis 
of quinsy could be made by the other symptoms. 

In most cases the recognition of quinsy is quite easy by attention to 
the symptoms above mentioned. By inspection of the throat less in- 
formation is sometimes obtained than by palpation; by this means a 



.108 DISEASES OF THE DIGESTIVE SYSTEM 

fulness, and later a point of fluctuation, can readily be made out. Acute 
phlegmonous tonsillitis generally involves no danger to life. In very 
young infants serious results may follow spontaneous rupture during 
sleep; and in older children occasionally there may be edema of the 
glottis. If not treated, abscess usually forms in from five to seven days. 
and opens spontaneously. 

Treatment. — Many drugs have been advocated, but to our minds the 
best is salol, which should be given in doses of two grains every two 
hours to a child of five years. In some patients larger doses may be 
used. This may be combined with small doses (gr. 14) of Dover's 
powder. Relief may be afforded by very hot or cold applications, ac- 
cording to the sensations of the patient. The holding of ice in the 
mouth and the application of an ice-bag externally, often give great 
comfort. In other cases, gargling with very hot water and the applica- 
tion of hot flaxseed poultices externally, will be preferred. As soon as 
fluctuation is detected an incision should be made with a guarded bis- 
toury. If made too early, only a small amount of pus is evacuated and 
the abscess may refill. After spontaneous rupture the relief to symp- 
toms is usually immediate. 



CHRONIC HYPERTROPHY OF THE TONSILS— CHRONIC TONSILLITIS 

The condition known as chronic hypertrophy is a permanent enlarge- 
ment due to a proliferation of the lymphoid tissue of the tonsils, and an 
increase in the connective-tissue stroma. If the increase in the con- 
nective tissue is slight, the tonsil is soft; if it is great, the tonsil is firm 
and hard, almost like a fibrous tumor. All degrees are found. Asso- 
ciated with hypertrophy of the tonsils there are usually found adenoid 
growths of the pharynx, both of these depending upon similar local and 
constitutional conditions. There is in nearly all marked cases a chronic 
pharyngeal catarrh which may involve the Eustachian tubes. 

Etiology. — Hypertrophy of the tonsils is an exceedingly common con- 
dition in the cities of the seacoast and lake districts of the temperate 
zone. In a routine examination of 2,000 New York school children, 
Chappell found enlargement of the tonsils sufficiently marked in 270 
cases to be considered pathological. The causes are constitutional and 
Local. The condition frequently exists in certain families for several 
generations. It occurs in children who are in other respects healthy. 
According to Czerny, overfeeding may produce tonsillar enlargement 
jus! as it does enlargement of the adenoid tissue of the rhinopharynx. 
The mosj importanl of the local causes are attacks of acute or subacute 
pharyngitis. While it is true that attacks of acute inflammation are 



HYPERTROPHY OF THE TOXSILS 309 

often the cause of hypertrophy, it is also true that hypertrophy is one 
of the most frequent predisposing causes of acute attacks, and that it may 
be seen in children who have never had acute tonsillitis. 

Symptoms. — Hypertrophy of the tonsils is rarely marked enough to 
cause any decided symptoms before the end of the second year, although 
occasionally in younger children enlargement sufficient to bring the two 
tonsils into contact' may be seen. The most important local symptoms, 
formerly ascribed to hypertrophied tonsils, are now known to depend 
upon adenoid growths of the pharynx. As these conditions are so fre- 
quently associated, it is somewhat difficult to determine which symptoms 
are due to the tonsils alone. In a marked case, the most prominent 
symptoms are mouth-breathing, disturbed sleep accompanied by snoring, 
and nasal voice — the patient in some cases talking as though he had 
food in his mouth. There may be some difficulty in swallowing solid 
food. Enlarged tonsils may often be felt externally. As a consequence 
of the obstruction of the Eustachian tubes there may be deafness. De- 
formities of the chest, such as pigeon-breast, are occasionally seen, but 
probably depend more upon obstructed respiration by adenoids than by 
the tonsils. 

There are seen in certain children tonsils which show only a very 
moderate amount of enlargement, but are of unhealthy appearance 
and are accompanied by low fever and other indefinite symptoms of 
illness which may persist for months. The tonsils appear to act 
in such cases as the avenue of absorption which results in a general 
infection. 

The soft tonsils may diminish somewhat in size spontaneously. They 
sometimes shrink very decidedly after an attack of acute tonsillitis, 
scarlet fever,, or diphtheria. As a rule the tonsils become firmer and 
harder as time passes. They usually increase in size up to a certain 
point, and then remain nearly stationary until about puberty, when 
they may diminish considerably. During intercurrent attacks of inflam- 
mation, the swelling is much increased, and the symptoms are propor- 
tionately aggravated. In cases of marked enlargement very little spon- 
taneous improvement- is to be looked for during childhood. 

Treatment. — Very large tonsils are a source of continued danger to 
the patient, and in every case of marked hypertrophy treatmenl should 
be advised. The danger may be from Eustachian catarrh and deafness, 
or from repeated attacks of acute tonsillitis. But quite as important as 
these is the fact that they increase the liability to contract diphtheria, 
and add to the dangers both from diphtheria and scarlet fever. If the 
patient is removed from the locality in which acute tonsillitis is liable to 
occur, to a dry climate, considerable improvement is likely to result in 
a young child in whom the tonsils are soft, but not much Is to be 



310 DISEASES OF THE DIGESTIVE SYSTEM 

expected in older children with hard, fibrous tonsils, except, perhaps, a 
cure of the accompanying pharyngeal catarrh. 

No internal remedy offers much chance of benefit. Astringent ap- 
plications may accomplish something in recent, but practically nothing 
in old cases. In every marked case, operation is the only thing which 
can be relied upon to effect a cure. For convenience of consideration, 
the cases may be divided into four groups: (1) Those in which the 
tonsils are nearly or quite in contact; (2) those in which they project 
only slightly beyond the faucial pillars; (3) those in which the tonsils, 
although large, are deeply imbedded; (4) diseased tonsils, though show- 
ing only moderate enlargement, especially when associated with tubercu- 
lous glands of the neck. All of the first group should unquestionably 
be operated upon, unless the patient's general condition is such as to 
forbid operation of any kind. In the second group operation is not indi- 
cated unless there are repeated acute attacks of inflammation. Whether 
an operation is done in the third group will depend upon the individual 
case. If there are frequent attacks of acute tonsillitis or evidence of 
involvement of the ears operation should be performed. In the fourth 
group operation is indicated if general symptoms are present. 

Of the various operations proposed for the removal of hypertrophied 
tonsils complete enucleation is clearly to be preferred. It is a painful 
operation, some preliminary dissection is usually required, and hence gen- 
eral anesthesia is necessary. The risk of serious hemorrhage in children 
is slight, but preparations should always be made to control it as even 
with non-bleeders one can never tell how severe it may be. Enlarge- 
ment of the tonsil subsequent to simple amputation is quite frequently 
seen, especially if the patient operated on is under two years old. 

We have more than once seen physicians greatly alarmed at the gray 
wound on the day following tonsillotomy, the appearance being such as to 
lead in several cases to the diagnosis of diphtheria. It is seldom that any 
but good results follow the operation of tonsillotomy if properly per- 
formed. When adenoids of the pharynx are also present, the symptoms 
may depend more upon them than upon the enlarged tonsils, and little 
benefit is seen unless the adenoids also are removed. 



ACUTE ESOPHAGITIS 311 

CHAPTER IV 
DISEASES OF THE ESOPHAGUS 

MALFORMATIONS 

Congenital anomalies of the esophagus are often associated with 
those of the lower part of the respiratory tract. 

There may be, (1) Congenital fistula of the neck, clue to a want of 
closure between the second and third branchial arches. This gives an 
external opening just above and to the outside of the sternoclavicular 
articulation, which communicates with the upper part of the esophagus 
or the lower part of the pharynx. (2) The esophagus may be absent, 
the pharynx ending in a blind pouch. (3) The esophagus may be oblit- 
erated in certain portions, being represented only by a fibrous cord. (-1) 
There may be stenosis and dilatation or diverticula. (5) There may 
be fistulous communication with the trachea, existing either alone or asso- 
ciated with some of the other deformities mentioned. This is the variety 
which we have most frequently met with. From above, the esophagus 
usually terminates in a blind pouch. From below, it communicates with 
the trachea a short distance below the larynx. The two parts of the 
esojDhagus are usually connected by a fibrous cord. 

Congenital narrowing of the esophagus and fistula of the neck are 
amenable to surgical treatment. The cases of complete obstruct ion in 
the esophagus are almost of necessity fatal, the patients dying from in- 
anition four or five days after birth. 

The symptoms of esophageal obstruction are regurgitation on at- 
tempts at swallowing and the impossibility of passing the stomach tube. 
An X-ray picture after the administration of bismuth often gives valu- 
able information. 

ACUTE ESOPHAGITIS 

It is quite remarkable, considering the frequency of patholo,-i< sal 
processes in the pharynx, that these so rarely extend to the esophagus. 
Thrush, when very extensive in the pharynx, may involve the upper part 
of the esophagus; but there it gives rise to no new symptoms. Diph- 
theria of the pharynx may invade the esophagus, but this is seen only 
in rare instances. Diphtheria of the esophagus produces no symptoms 
by which it can be diagnosticated during life. 

Catarrhal Esophagitis. — Catarrhal esophagitis is very rarely met 



312 DISEASES OF THE DIGESTIVE SYSTEM 

with. It may be caused by lacerations due to swallowing a foreign body, 
which may excite a simple catarrhal inflammation, or, if the foreign 
body is sharp and angular, lacerations may be produced which result in 
ulcerations of variable depth. The chief symptoms of catarrhal esoph- 
agitis are soreness and pain on swallowing. These lacerations, when slight, 
are healed in a few days, and are rarely followed by any after-effects. 

Corrosive Esophagitis. — This is altogether the most frequent form, 
and the only one which is of clinical importance. The usual causes are 
the same as of corrosive gastritis, viz., the swallowing of caustic alkalis 
or strong acids. It is often in the esophagus that the most extensive 
injury is done. The effects are superficial or deep, according to the 
amount of the irritant swallowed and its degree of concentration. There 
may be simply a destruction of the epithelial layer, which is followed by 
no serious consequences, or the mucous membrane may be destroyed and 
t lie submucous coat invaded; rarely, however, does the injury extend to 
the muscular layer. If the patient survives the dangers incident to the 
irritant poisoning and the acute inflammation which follows, healing by 
granulation and cicatrization takes place, the contraction of the cicatrix 
gradually narrowing the lumen of the esophagus until stricture is pro- 
duced. 

The early symptoms of corrosive esophagitis are mingled with those 
of inflammation of the mouth, pharynx, and stomach. There is a burn- 
ing pain in the parts, great thirst, and spasm of the esophagus on at- 
tempts at swallowing. There follows a period of acute inflammation of 
several days' duration, with great dysphagia and pain, in which the 
principal danger is edema of the glottis. After this the patient may 
be comparatively well until the symptoms of stricture begin, usually in 
from three to six months after the injury. 

The indications for treatment in the early stages are, to neutralize the 
caustic in order to prevent if possible its deep action, to give oils, demul- 
cent drinks and ice for the local effect, and morphin for the pain. 

The treatment of esophageal stricture is purely surgical. 



RETROESOPHAGEAL ABSCESS 

Acute retroesophageal abscess occurs in infancy, though very rarely, 
the pathology being the same as in acute retro-pharyngeal abscess, the 
difference being merely one of location. A striking case of this kind 
occurred in the New York Foundling Hospital. An infant six months 
old w;is admitted with no loss of voice but with high fever (104° F.) 
and severe dyspnea which were the prominent symptoms until death 
occurred four days later. There was a leucocytosis of 100,000. At 



RETROESOPHAGEAL ABSCESS 313 

autopsy an abscess was found containing about three ounces of pus be- 
tween the esophagus and the spine, extending from the larynx to below 
the bifurcation of the trachea. Shortly afterward a very similar case 
occurred at the Babies' Hospital, following a retro-pharyngeal abscess 
which had been opened two weeks before. Similar abscesses have also 
been observed after acute pharyngitis with the acute infectious diseases. 

Eetro-esophageal adenitis, or enlargement of the lymph nodes in 
this situation without suppuration, is also rare. We once met with a case 
of this sort in which the gland formed a tumor nearly an inch in diam- 
eter at the upper part of the esophagus, causing pressure symptoms 
necessitating tracheotomy. The growth was at first thought to be malig- 
nant, but completely disappeared after a. summer in the country. 

Eetro-esophageal abscess may result from the breaking down of 
tuberculous lymph nodes in the posterior mediastinum, and may give rise 
to symptoms like those which result from an abscess due to Pott's disease. 

Perforation of the esophagus and a food-fistula connecting the esoph- 
agus and the trachea may result from ulceration caused by a tracheal 
canula or by a foreign body. This may be accompanied by abscess. 

The most common variety of retro-esophageal abscess is that due to 
Pott's disease of the lower cervical or upper dorsal region. The symp- 
toms are obscure, and an exact diagnosis is not often made during life. 
Death may occur quite suddenly when the previous symptoms have been 
so slight as to be easily overlooked. The following is a fair example: 

A girl two years old was admitted to the Babies' Hospital with caries 
of the upper dorsal region of two months' duration. The patient was 
kept in bed and a plaster-of- Paris jacket applied. About a month later 
dyspnea was first observed; this was at times quite intense, and again 
almost absent. It was always on inspiration, expiration being easy. Xo 
explanation for this was found in the lungs. There was no difficulty in 
swallowing, and very little cough. After these symptoms had lasted for 
about a week, the child while eating was suddenly seized with violent 
dyspnea, and in a few moments became completely asphyxiated. Trache- 
otomy was immediately done, and by means of artificial respiration the 
patient was restored to comparative comfort. About two hours later a 
second attack occurred, and the patient died in an hour. At the autopsy 
there was found an abscess a little larger than a lien's egg. containing 
about two ounces of curdy pus, overlying the bodies of the first three 
dorsal vertebrae and communicating with them. These vertebrae were 
carious. The right pneumogastric nerve, an inch and a half above the 
bifurcation of the trachea, was compressed between the abscess and a 
large tuberculous lymph node, with the capsule of which it was blended. 
In the lungs were a few small tuberculous deposits and the usual condi- 
tions found in death by asphyxia. The dyspnea seems to have been of 



314 DISEASES OF THE DIGESTIVE SYSTEM 

nervous and not of mechanical origin, and caused by irritation of the 
pneumogastric. The fatal issue was apparently from an increase of the 
pressure upon the nerve. 

We have seen but one other case, and this closely resembled the one 
reported. In the thirteen cases collected by Griffith the symptoms in all 
were much alike. Dyspnea, usually of a spasmodic character, was 
prominent in nearly all, and generally it was the most prominent symp- 
tom. It was more marked on inspiration, and often accompanied by a 
spasmodic cough, suggesting laryngeal stenosis. The voice was affected 
in but two cases, in one complete aphonia being present. It is striking 
that in no case was there any difficulty in swallowing, in marked con- 
trast to retropharyngeal abscess. Swelling in the neck was noted in but 
three cases. Spinal caries was stated to be present in seven cases and 
absent in two. The final attack of asphyxia sometimes came without 
warning, sometimes was preceded for several days or longer by milder 
attacks. 

The diagnosis of this condition is very difficult, and a positive diag- 
nosis almost impossible. It may be suspected in cases of Pott's disease 
of the lower cervical or upper dorsal regions, when there is spasmodic 
inspiratory dyspnea, especially if accompanied by irritative cough. It 
should, however, be remembered that precisely similar symptoms may 
depend upon the irritation of a tuberculous node, and that the sudden 
asphyxia is exactly like that caused by the ulceration of such a node 
into the trachea or a large bronchus. The latter, however, may occur 
without the presence of Pott's disease. If the abscess is higher up, there 
may be a swelling on either side of the neck, just above the clavicle. 
In most of the cases there are no external signs of disease. Such 
a bscesses are too low to be reached by digital examination of the pharynx. 
The attack of asphyxia may also be confounded with that due to the 
presence of a foreign body in the larynx. 

The prognosis in cases of retro-esophageal abscess is exceedingly bad. 
Death usually results from pressure upon the pneumogastric, as in the 
cases reported. The abscess may rupture into the esophagus and recov- 
ery fellow. This termination is very rare, but such a case has been re- 
ported by Knight. A fatal one is reported by Loschner and Lambl. The 
abscess may burrow along the esophagus into the abdominal cavity and 
excite peritonitis; finally, it may open externally. 

But little is to be said under the head of treatment. The symptoms 
are rarely definite enough to justify a radical surgical operation. Trache- 
otomy gives but temporary relief to the asphyxia. This operation should 
be performed, however, in every case, because of the impossibility of 
making a diagnosis of retro-esophageal abscess from other conditions 
in which the operation might be curative. 



DIGESTION IN INFANCY 315 

CHAPTER Y 

DISEASES OF THE STOMACH 

It is difficult wholly to separate diseases of the stomach from those 
of the intestine. Although in older children they are often quite dis- 
tinct, in infancy they are more frequently associated; but at one time 
the gastric symptoms may be prominent, and at another the intestinal 
symptoms. Functional disorders particularly are likely to involve the 
whole tract. Serious organic lesions are more frequently limited in 
their extent either to the stomach or to the intestine. The former are 
rare, while the latter are very common. The diseases in which the stom- 
ach is alone or chiefly involved will be considered by themselves. Those 
in which both the stomach and intestine are involved are classed with 
the intestinal diseases, as the intestinal symptoms usually predominate. 

DIGESTION IN INFANCY 

The first step in the process of digestion in the newly-born infant is 
sucking. During this act the nipple is grasped between the lower lip and 
tongue below, and the upper lip and jaw above. The back of the mouth 
is closed by the palate. A strong downward movement of the lower jaw 
causes a partial vacuum in the mouth, and produces the suction force 
which causes the milk to flow. Sucking can be carried on only when the 
nose is free for respiration and the palate and upper jaw intact. Chil- 
dren with deformities of the mouth, like cleft palate and harelip, suck 
only with the greatest difficulty, and complete nasal obstruction prevents 
nursing. 

The Saliva. — This is present at birth only in very small amount, and 
the part which it plays in digestion in early infancy is an insignifi- 
cant one. During the third and fourth months it increases markedly in 
quantity, and at this time it possesses quite actively the power of trans- 
forming starch into sugar. This property is present only to a very slight 
degree during the early weeks. 

The Stomach. — Our knowledge of the anatomy and physiology of the 
infant's stomach has been greatly increased through the use of the X-ray. 
The position varies considerably in normal conditions and very greatly 
in pathological conditions. The stomach is usually somewhat obliquely 
situated in the abdomen, not only from side to side, but from before 
backward, as the cardiac orifice is quite near the spine while the pylorus 
is much anterior. The pylorus is usually considerably to the right of 



316 DISEASES OF THE DIGESTIVE SYSTEM 

the median line and generally situated somewhat behind the pyloric third 
of the stomach. 

When inflated after death the normal infant's stomach resembles 
a curved cylinder with a greatly shortened superior border. After 
the first year the great development of the fundus occurs and the shape 
is much like that of the adult stomach. During life the shape of the 
stomach varies greatly with the amount of food and gas it contains and 
with the condition of its muscular walls, whether relaxed or contracted. 
It enlarges with great facility with the introduction of food. In con- 
ditions when there is a lowered muscular tone, as in rickets or mal- 
nutrition, great changes in size, shape and position are met with. In 
some cases the stomach is almost entirely to the left of the median line. 
The abnormal shapes are temporary or permanent, according to cir- 
cumstances, and no doubt have much to do with the facility with which 
.the stomach empties itself during digestion. 

In the nursing infant, food begins to leave the stomach almost at 
once, and within five minutes a very considerable proportion of the 
amount taken has often reached the intestine. At the end of half an 
hour the greater part of the food has usually left the stomach. In 
infants taking cow's milk, the food passes out more slowly but after the 
first few minutes food is seen in the intestines. The opening of the 
pylorus is much influenced by the reaction of the gastric contents. It 
normally opens when a certain degree of acidity is reached. The addi- 
tion of alkalis to cow's milk markedly delays the emptying of the stom- 
ach. This is also influenced • by the composition of the food; when the 
food contains a high fat percentage, emptying of the stomach is much 
delayed. The whey first reaches the intestine, afterwards the casein, 
and lastly the fat. Solid food is retained in the stomach a longer time 
than milk. 

The stomach always contains gas, and, by the X-ray, after every 
feeding a large bubble of gas is seen above the food, often half filling 
the stomach. Most of this gas is air that has been swallowed. In 
conditions of disordered digestion the amount may be very great. There 
is a natural tendency for the stomach to contract and expel this gas 
after taking food; but if the infant is placed upon his back and kept 
there, this is mechanically impossible, as has been well shown by the 
Investigations of C. H. Smith. 

Gastric Digestion. — The role of the stomach in digestion is not so 
important in infants as in adults. The gastric part of digestion is only 
preliminary and partial; the major part of digestion takes place in 
the intestines. While the function of the stomach is largely that of a 
reservoir into which the milk is received and from which it is allowed 
to pass gradually into the intestines, certain definite changes take place 



DIGESTION TX INFANCY 317 

there chiefly owing to the activity of the rennet ferment and the gastric 
lipase. It was until recently believed that the action of the gastric 
juice was chiefly upon the protein of the food by virtue of the pepsin 
and hydrochloric acid contained in it. It has been shown, however, 
that for each gastric ferment a certain concentration of acid is neces- 
sary for its activity. In a large series of cases, different observers have 
determined that the concentration of acid in the gastric juice of normal 
infants fed upon cow's milk is low, much less than that of adults. Pepsin 
is inert in a solution of such weak concentration. It is therefore alto- 
gether probable that gastric digestion by pepsin is practically negligible. 
Nevertheless, pepsin is found in the stomach at birth and may even 
be demonstrated in the fetus as early as the fourth month. 

The concentration of acid in the stomach, although insufficient for 
the action of pepsin, is sufficient for the activity of the rennet ferment 
and the lipase. Coagulation is the first change which milk undergoes 
in the stomach. Woman's milk coagulates in loose flocculi and quite 
imperfectly, while cow's milk coagulates in much firmer, more compact 
masses, owing to the larger amount of casein. The motility of the 
stomach plays an important part in digestion. The churning movements 
soon break up these casein masses into much smaller particles. Eennet 
has a feeble digestive action upon protein. Many good authorities con- 
sider that rennet is not a separate substance but that coagulation is one 
of the properties of pepsin. The question is as yet undecided but pepsin 
and rennet are always present in coresponding amounts. It has been 
shown that a lipase or fat-splitting ferment is present in the stomach 
even of infants and that it increases the activity of the pancreatic lipase. 
Its importance in the stomach is not clearly known. 

Pepsin is found in the stomach at birth, and even in the fetus as 
early as the fourth month. In fifteen minutes after feeding the reaction 
of the stomach contents is always acid. Free hydrochloric acid can not 
usually be demonstrated until about an hour after feeding, then only in 
small quantities, and in very many cases not at all. The reason for this 
is, that the acid combines with the casein and the salts of milk, those of 
cow's milk in particular having a great power of combining with hydro- 
chloric acid. 

The duration of gastric digestion varies with the age of the infant 
and with the food. During the first month the stomach of healthy 
nursing infants is usually found empty in an hour and a half after 
feeding, often in one hour. In those taking cow's milk the average is 
at least one hour longer. In infants from two to eight months old 
the average is two hours for those receiving breast milk, and two and a 
half to three and a half hours for those fed upon cow's milk. The time 
is influenced by the size of the meal taken and by tin' composition «»f 
12 



318 DISEASES OF THE DIGESTIVE SYSTEM 

the food. The higher the proportion of fat in the meal, the longer the 
food is retained in the stomach, and also the smaller the amount of 
gastric juice secreted. Yery little absorption takes place from the stom- 
ach. There is here absorbed a certain proportion of sugar and peptones, 
but practically no water, fat, or salts. The amount of gastric juice 
secreted is very large. In experiments upon animals it has been shown 
to be nearly as great as the volume of milk taken. 

The bacteria of the stomach are very few as compared with those of 
the intestine, and no varieties are constantly present. 

The Intestines. — The length of the small intestine at birth is about 
nine feet; that of the large intestine about eighteen inches. The great 
length of the sigmoid flexure is the most striking peculiarity, this being 
nearly one-half the length of the large intestine. 

Intestinal Digestion. — All the important elements of food — protein, 
carbohydrates, and fat — are acted upon by the pancreatic juice. The 
protein is converted into peptones by trypsin. The digestion of protein 
is completed by the erepsin of the intestinal juice, which converts pep- 
tones and albumoses into amino acids. In this form the nitrogenous 
portion of the food is finally absorbed. 

The amylolytic ferment of the pancreas has the power of converting 
starch into maltose. This action is feeble during the first four or five 
months, but is present even in early infancy. Milk sugar is changed into 
galactose and glucose, and cane sugar and maltose into glucose through 
the agency of the intestinal and pancreatic juices. Fats are partly emul- 
sified and partly saponified by the pancreatic juice in connection with 
the bile. 

Ao sorption. — From the small intestine absorption takes place very 
rapidly. The protein is absorbed in the form of peptids and amino acids. 
Sugars of all varieties are changed to glucose during absorption. Fat is 
absorbed in the form of fatty acids and soaps; but in their passage 
through the wall of the intestine the fatty acids are converted into 
neutral fats. Absorption from the large intestine, except of water, is 
quite imperfect. Fat absorption is very slight. Sugar, salts, and pep- 
tones, however, may be absorbed with moderate facility. 

Intestinal Bacteria. — For the fundamental work upon this subject we 
are indebted to the researches of Escherich. Bacteria are absent from 
the entire gastro-enteric tract at birth. They quickly enter by the mouth 
and rectum, and by the end of twenty-four hours they are usually found 
in ;ill parte <>l' (be intestinal tract. The meconium bacteria are derived 
from the inspired air, and hence vary somewhat with surroundings. As 
sood as the ingestion of milk begins these varieties are displaced, and 
throughout the period in which (be infant has ibis food exclusively, there 
have been found in healthy conditions but i'vw varieties which are con- 



FECES 319 

stantly present. These are the b. lactis aerogenes the b. coli communis, 
and the b. bifid us. The number of bacteria varies in different parts of the 
intestine. They are found in greatest numbers in the cecum and colon, 
and are relatively few in the small intestine. The b. lactis aerogenes 
is found most abundantly in the upper part of the small intestine, in 
small numbers only in the colon, and usually there are none in the 
feces. 

The b. coli communis is found in but small numbers in the upper 
small intestine, becoming more abundant lower down. In the colon and 
in the feces it is present in considerable numbers. The most abundant 
organism in the large intestine, however, is the b. bifidus. A change 
from a milk diet to a mixed diet of meat and farinaceous food produces 
a marked change in the character of the intestinal bacteria. 

Feces.- — The first discharges after birth consist of meconium; this is 
of a dark brownish-green color, semi-solid, and usually passed from 
four to six times daily during the first two or three days. On the thin I 
day the stools begin to change in character, and by the fourth or fifth 
day they have usually assumed the appearance of normal milk-feces. 
Under many abnormal conditions the stools may continue to have the 
character of meconium for a week or more. Meconium is composed 
of intestinal mucus, bile, the vernix caseosa, epithelial cells from the 
epidermis, hairs, fat-globules, and cholesterin crystals. For its forma- 
tion there are necessary the secretions of the intestine and the liver and 
the swallowing of a considerable amount of amniotic fluid. 

Milk-feces. — The amount of feces discharged daily by a healthy 
nursing infant is from two to three ounces (60-90 gms.). Such stools 
have the color of the yolk of egg but may be paler, and from time to time 
even slightly greenish. They are seldom entirely smooth and homogene- 
ous but usually contain a large number of small light-yellow particles. 
The consistency is butter-like, but often rather looser than this. Under 
normal conditions the stools are never watery. The reaction is acid, and 
there is a slightly sour but not unpleasant odor. The reaction is due 
to the presence of fatty acids or lactic acid. The color depends upon 
bilirubin. The stools of an infant fed upon cow's milk may, in con- 
ditions of perfect digestion, differ in no respect from those just de- 
scribed; usually, however, they are firmer, rather more homogeneous, 
of a paler yellow color, and may be neutral or even alkaline in read ion. 
The normal stool of a nursing infant contains aboul 85 per cent of water 
and 15 per cent of solids; that of one taking cow's milk has aboul 
per cent water and 20 per cent solids. 

The only gases present are hydrogen and carbon dioxid. Sulphur- 
etted hydrogen and marsh gas, to which the odor of adult .-tool- is largel) 
due, are not present. 



320 DISEASES OF THE DIGESTIVE SYSTEM 

The solids of the stools are chiefly fat, salts and nitrogenous matters. 
Sugar is not found, but its derivative, lactic acid, may be present in small 
amount. The fat makes up from 20 to 40 per cent of the dried matter, 
and is in the form principally of soaps and fatty acids, with a smaller 
proportion of neutral fats The inorganic salts form about 10 per cent 
of the solids of the breast-milk stool, and from 20 to 35 per cent of the 
solids of the cowVmilk stool, about three-fourths of this being calcium 
phosphate. The nitrogenous elements of the cowVmilk stool make up 
aboul 25 per cent of the dried residue, but only a small proportion of 
this represents unabsorbed protein. They are chiefly derived from the 
intestinal secretions and the bodies of bacteria. Amino acids, represent- 
ing unabsorbed food protein, make up from 2.1 to 21 per cent of the 
nitrogen of the stool. The protein of woman's milk is almost entirely 
absorbed, and that of cow's milk largely so, under almost all condi- 
tions. 

A healthy nursing infant absorbs about 85 to 90 per cent of his in- 
gested fat, about 95 per cent of his protein, and about 80 to 85 per 
cent of bis salts. A healthy infant taking cow's milk absorbs about 85 
to 90 per cent of his ingested fat, about 90 to 95 per cent of his protein, 
and about 60 per cent of his salts. 

Tlie biliary elements present in the stool are hydrobilirubin, un- 
changed bilirubin, and cholesterin. The presence of biliary acids is 
doubtful. Mucus is always present in considerable quantity. 

Microscopically there are seen epithelial cells, chiefly of the columnar 
variety, a few round cells, mucous corpuscles, fat globules and crystals 
of fatty acids, cholesterin, mucin, crystalline inorganic salts, some- 
times bilirubin in crystals, yeast fungi, and bacteria in immense num- 
bers. 

If the infant is taking a food containing starch, this may appear to 
a greater or less extent in the stools, a larger amount in the case of very 
young infants. 

The number of stools of breast-fed infants during the early weeks is 
from two to six daily. After the first month two stools a day are the 
average; many infants have three, many others but one. With modified 
cow's milk the stools are seldom more than one or two a day and there 
is frequently constipation. 

As soon as an infant is put upon a mixed diet, the peculiar charac- 
ters of the stools disappear, and they come to resemble more closely those 
of the adult, though remaining softer throughout infancy. They be- 
come darker in color and assume the adult odor, while retaining their 
acid reaction. The bacteria, while still in great numbers, are more 
varied than are met with in milk-feces. 



HYPERTROPHIC STENOSIS OF THE PYLORUS 321 



MALPOSITIONS AND MALFORMATIONS OF THE STOMACH 

The stomach is sometimes in the thoracic cavity in cases of diaphrag- 
matic hernia. It may be found in a vertical (fetal) position, variously 
adherent to the colon and small intestine. Malformations are much less 
frequent than those of other parts of the alimentary tract. There may 
be atresia or stenosis at either orifice, and very rarely a constriction is 
found near the middle of the organ, dividing it into compartments. The 
symptoms of atresia at either orifice are persistent regurgitation or 
vomiting, and death in a few days from inanition. 



HYPERTROPHIC STENOSIS OF THE PYLORUS 

This condition known also as congenital stenpsis of the pylorus, or 
simply as pyloric stenosis of infancy, is not an uncommon one. It is 
characterized by persistent vomiting, constipation, wasting, marked visi- 
ble gastric peristalsis, and usually a palpable tumor. It is a serious 
condition, and unless recognized early and properly treated it has a 
high mortality. It is seen in early infancy, usually in the first two 
months of life but seldom in the first two weeks. Fully four-fifths 
of the cases occur in male infants. It has no relation to feeding, the 
large proportion of recorded cases having been seen in nursing in- 
fants. 

The pathology of stenosis of the pylorus in early infancy is some- 
what obscure and at the present time quite diverse views are held. It 
is believed by some that the primary and essential condition is one of 
spasm; that the hypertrophy when it is present is secondary; that in a 
very considerable proportion of the cases there is only pylorospasm with- 
out hypertrophy ; that with proper medical treatment most cases recover, 
and that surgical intervention is rarely called for. The other view and 
that which seems to harmonize best with the clinical symptoms and the 
pathological findings is that the primary condition is one of hypertrophy 
which is congenital; that to this, spasm is added ; that in all cases both 
factors — hypertrophy and spasm — are present; that while the case- differ 
in degree they are the same in kind; that while many of the milder ones 
may recover without operation the severer ones should be treated sur- 
gically. Spasm certainly plays an important part in the product ion of 
symptoms; but to regard this condition as one essentially of muscular 
spasm seems to us erroneous. 

The appearance of the pylorus when seen at autopsy or operation 
is remarkably uniform. Ii forms a hard, whitish tumor about the si/..- of 



322 DISEASES OF THE DIGESTIVE SYSTEM 

a peanut, of almost cartilaginous consistency. Its lumen may be so nar- 
rowed as barely to admit a tine probe, while the normal pylorus will 
usually admit a No. 21 sound, French scale. Frequently water can not 
be forced through the stenosis owing probably to the fact that the mucous 
membrane is thrown into folds. The walls of the stomach are often 
hypertrophied, especially toward the pyloric end. The stomach is usually 
much dilated; its lower border may be below the navel. On section 
the pylorus is found to be much thickened and by microscopical exami- 
nation this is seen to be chiefly of the circular muscle fibers. This coat 
appears to be two or three times the normal thickness. The other coats 
— submucous, mucous and longitudinal muscular — are thickened but to 
a much less degree. 

Symptoms. — The clinical picture is a striking one. Symptoms rarely 
begin in the first week of life. An infant who for the first two or three 
weeks has usually shown no signs of gastric disorder, and often has 
been nursing and gaining regularly in weight, begins, without evident 
cause, to vomit; at first occasionally, but soon habitually. This vomiting 
in a short time becomes forcible, projectile. It may be of this type 
almost from the outset. Changes in diet have but a temporary effect 
upon it, or none at all. The bowels are constipated. The infant wastes 
steadily, the scales often showing a loss of one or two ounces a day. 
There is no fever and little or no evidence of pain. There is progressive 
failure in nutrition and death may occur from exhaustion in from four 
to six weeks from the beginning of marked symptoms. 

Vomiting. — The manner of vomiting is characteristic. It is more 
forcible than (hat seen under any other condition. An infant will often 
fairly shoot out the contents of the stomach to a distance of three or 
four feet. Food frequently comes through the nose. The vomiting 
usually has a relation to the taking of food. It most frequently comes 
directly after feeding, sometimes even while the child is still at the 
breast. After an attack of vomiting, nursing is sometimes resumed with 
avidity, showing a distinct absence of the usual symptoms of gastric 
indigestion. All the food is generally expelled at one time. The fre- 
quent regurgitation of small amounts is unusual. Generally vomiting 
does not occur at night unless the child is nursed at that time. The 
vomited matters at first consist only of food, often but little changed. 
Aiter a lime there is mucus, sometimes in large quantities. The amount 
vomited at one time is often considerably greater than the feeding just 
I a ken. Indicating a considerable retention of food in the stomach. Some 
of these children vomit regularly after every feeding; others retain 
two or three feedings and then expel the whole amount. The frequency 
of vomiting varies from once or twice to six or eight times a day. Owing 
io the loss of fluid by vomiting (he urine is usually very scanty. There 



HYPERTROPHIC STENOSIS OF THE PYLORUS 323 

is no uniform change in the gastric secretions, but there is frequently 
hyperacidity present. 

Bowels. — Obstinate constipation is the rule. It is due to the fact 
that so much of the food taken is vomited. If the pyloric obstruc- 
tion is complete the stools resemble meconium. 

Wasting. — Progressive wasting is one of the striking symptoms, and a 
close observation of the weight one of our best guides to the progress of 
the case. If the loss amounts to two or three ounces a (lav the condition 
should be considered most critical. The rate of the loss depends naturally 
upon the completeness of the obstruction and it is proportionate to the 
amount of vomiting and the degree of constipation. 

General A pijeamnce. — At first nothing abnormal is seen, but soon 




Fig. 31. — Gastric Peristalsis in Pyloric Stenosis. (Thomson.) 
Patient eight weeks old. 

all the evidences of rapid malnutrition are present, without, however, the 
other usual symptoms of indigestion, such as might be expected with the 
vomiting. The tongue is usually clean; the appetite often voracious; 
there are no eructations of gas ; the breath is sweet, and the color usually 
good. 

Peristalsis. — On examination of the abdomen the epigastrium i< usu- 
ally full and the lower half of the abdomen may be sunken. If the skin 
is bared and the patient placed in a good light the characteristic peristal- 
tic waves are seen which are the most diagnostic feature of the disease. 
One should not expect to see them if the stomach is empty; they are 
best seen immediately after taking food or water. When not appearing 
spontaneously they may often be excited by slight friction or tapping of 
the epigastrium. There is seen a slowly moving wave from left to right. 
First a ball-like tumor appears just below the ribs on the left side (see 
Fig. 31). It is usually about one and a half to two inches in diameter 
and slowly moves toward the right. It usually < I isa { >| >«;i r- ju>i beyond 



324 DISEASES OF THE DIGESTIVE SYSTEM 

the median line. Sometimes one wave is quickly followed by another. 
Peristalsis of the intestine, in rare eases, may somewhat resemble these 
movements; but typical gastric contractions can hardly be mistaken for 
anything else. After marked peristalsis vomiting frequently occurs. . 

Tumor. — The hardened pylorus can with experience be felt in most 
cases. It may be obscured by distention of the stomach or the colon or by 
enlargement of the liver. The pylorus may be displaced. The position 
of the tumor is therefore of less importance in diagnosis than its char- 
acter. It is usually felt about one and a half to two inches below the 
free border of the ribs, just inside of the right mammary line. It may be 
felt only during active peristalsis. It appears somewhat smaller than the 
little finger and about three-fourths of an inch long. 

Gastric Retention. — The prolonged retention of food in the stomach 
is one of the characteristic features of pyloric stenosis. In healthy 
nursing infants the stomach is regularly found empty at the end of three 
1 lours, often at the end of two hours. But if stenosis is present, food 
in considerable amount is almost invariably found after three hours and. 
unless vomiting has occurred, usually after four hours. Sometimes this 
is also the case when there has been vomiting. This retention varies in 
amount, but when there has been no vomiting for several hours a larger 
amount may be removed than the last feeding taken, sometimes twice 
as much. Early in the morning after fasting eight or ten hours the 
stomach may contain three to four ounces of partly digested food. Ab- 
normal gastric retention is one of the diagnostic features of pyloric 
stenosis. Gastric retention is best estimated by the removal of the stom- 
ach contents by means of suction. By this it can be determined how 
rapidly the food leaves the stomach quite as accurately as by the X-ray 
and in a much more convenient way. Not only is the X-ray unnecessary 
for diagnosis, but the administration of the large doses of bismuth for 
diagnostic purposes is objectionable and may even be dangerous in these 
very young patients. We have known of two instances in which its use 
was apparently the factor which determined the fatal result. 

Course of the Disease. — Two types of cases are seen: (1) the severe 
form, in which the peristalsis and vomiting are but little influenced by 
medical treatment; the loss of weight is continuous and often amounts 
to two or three ounces a day; there is very little fecal matter in the 
stools; the constipation is very marked, and, unless relieved by opera- 
tion, the condition generally proves fatal in from two to four weeks; 
(2) the mild form, in which the symptoms, though characteristic, are 
all much less marked, gastric peristalsis and tumor are present, but 
the vomiting is only occasional, fecal stools are passed, the loss of weight 
is not so marked and progress may alternate with periods of improvement 
m which there is gain in weight. Very many of these cases recover 



HYPERTROPHIC STEXOSTS OF THE PYLORUS 325 

without surgical aid, the chief danger being that the feeble infant is cut 
off by intercurrent disease. Whether there is a chronic form of infantile 
stenosis which persists into later childhood seems probable, but is not vet 
established. 

Diagnosis. — The diagnosis of pyloric stenosis of infancy is usually 
easy after a few days of observation, but may be impossible at the first 
examination. The time of onset and nature of the vomiting are strongly 
suggestive but not quite conclusive. The abrupt development in a nurs- 
ing infant from two to four weeks old of severe vomiting without as- 
signable cause and its persistence in spite of all treatment, should always 
lead to the suspicion of pyloric stenosis. The diagnostic features of 
this condition are three : waves of gastric peristalsis, abnormal gastric 
retention and a tumor. The existence of a tumor may be a matter of 
some uncertainty in many cases, but its presence is of considerable posi- 
tive value. The condition has been mistaken for cerebral disease on 
account of the projectile vomiting and chronic constipation; for renal 
disease, because of the vomiting and scanty urine. Usually, however, 
the only difficulty is to distinguish between the vomiting of gastric 
indigestion and that of pyloric stenosis. Gastric indigestion is an ex- 
ceedingly common symptom in infancy; but it is not very common in 
nursing infants and rarely develops suddenly. The vomiting is apt to be 
in small quantities and many times repeated and generally occurs at a 
longer period after feeding. There are undoubtedly some cases of 
gastric indigestion in early infancy in which a temporary pylorospasm 
occurs, but this condition is quite different from the one we have under 
consideration. The existence of persistent spasm of the pylorus without 
hypertrophy has yet to be proven. 

Impairment of motility is a symptom of gastric indigestion but in this 
condition the food seldom remains in the stomach for so long a time or 
in such amount as in stenosis. Besides it is unaccompanied by gastric 
peristalsis or a tumor. 

Congenital obstruction of the duodenum or other part of the small 
intestine may lead to persistent, forcible vomiting and, if the obstruction 
is high up, even to visible gastric peristalsis. But in these cases, whether 
due to stenosis, atresia, twisting or pressure from bands, the symptoms 
appear soon after birth and the severe forms are fatal in a few days. The 
vomited matters consist of bilious material. 

Prognosis. — Statements regarding prognosis will depend much upon 
what cases are included under the diagnosis. Limiting the term to the 
cases defined in the beginning of this article, the condition must be 
considered a serious one, often ending fatally unless properly treated. 
By older methods of treatment, fully 50 per cent of the children died. 
Of the last 50 operations done at the Babies' Hospital, the mortality was 



326 DISEASES OF THE DIGESTIVE SYSTEM 

28 per ecu I, but these (figures include a considerable number of cases 
admitted very late in the disease in which the patients' condition was 
apparently hopeless when operated upon. With a fairly early diagnosis 
and resort to surgical treatment, the mortality in skilled hands should 
not be over 10 or 15 per cent. In any given case the unfavorable symp- 
toms are, rapid and continuous loss in weight, i. e., one to three ounces 
a day, continued vomiting and meconium-like stools, both showing that 
little or nothing passes the pylorus. The lower the body weight has 
fallen before operation, the worse the prognosis, although we have seen 
a child recover whose weight at the time of operation was only four and 
a quarter pounds. 

In cases not operated on complete recovery may result, though, the 
tumor and active gastric peristalsis may persist for seven or eight 
months. Whether this condition may give trouble in later life cannot 
yet be definitely stated. The hypertrophy is certainly very slow in dis- 
appearing. A tumor has been found at autopsy in children dying of 
intercurrent disease as long as six months after recovery from all 
symptoms. 

Of 122 cases which have come under our observation, chiefly in the 
Babies' Hospital, the general mortality was 43 per cent. But these fig- 
ures include a very large proportion of severe cases, and many that were 
admitted very late and were in a hopeless condition. 

Treatment. — The treatment adopted will depend upon the type of 
case with which we have to deal. With all cases, medical treatment 
should be given a faithful trial. If the patient is seen early this may 
safely be continued for a period of at least one or two weeks. With 
a large proportion of those previously classed as belonging to the mild 
type, medical treatment will be successful. The cases which are likely 
to recover usually show decided improvement in a few days, — less vomit- 
ing, fecal stools, diminished peristalsis and a stationary or slight gain 
in weight. If, however, when first seen, symptoms have already lasted 
three or four weeks without material improvement, or if there has been 
a steady though not rapid loss in weight, operation should be advised. 
Though some of these cases might recover without it, the risks of waiting 
are greater than the risks of the operation. Again, operation should be 
resorted to early in all cases classed as the severe type which show no 
improvement by medical treatment in a few days. If the child's con- 
dition is bad, no delay is admissible. 

Medical Treatment. — This is carried out on the theory that the 
pyloric spasm to which symptoms are chiefly due will gradually subside 
if nutrition can he maintained. It consists in diet and stomach washing. 
II' a child is nursing and the milk is normal, weaning is not advisable. 
Small meals, not too near together, are essential. The breast should 



HYPERTROPHIC STENOSIS OF THE PYLORUS 327 

be given at four-hour intervals, and the nursing period varied from two to 
five minutes, according to the amount obtained. It is often advantageous 
to pump the breasts and give a measured amount of breast-milk. Usually 
for a child a month old not more than two ounces should be allowed at 
one feeding. On no account should an infant be weaned immediately 
because of the development of the symptoms of pyloric stenosis. For 
some infants who have been artificially fed nothing succeeds as well as 
a wet-nurse. The chief objection to the breast-milk is its high fat which 
sometimes increases the vomiting. 

For infants who are artificially fed a few general principles are pretty 
well established. In all milk formulas the fat should be low, usually 
less than that in formulas from whole milk. The formulas from skimmed 
milk usually succeed best. Feeding should be regular and not oftener 
than every three hours, and in many cases a four-hour interval is better. 
The amount given at one time should be from one and a half to three 
ounces. 

Stomach washing is useful to empty the organ of food and mucus 
and seems to have some effect in allaying spasm. Water used should 
have a temperature of 108° to 110° F. and be rendered alkaline by the 
addition of one per cent of bicarbonate of soda. The washing should 
be done about two and a half hours after feeding, and repeated twice in 
twenty-four hours. It should be continued for a considerable period. 
In .cases which recover it has often been found necessary for six to eight 
weeks, twice daily, and for three or four months once daily. Hot appli- 
cations over the epigastrium are of little value in relaxing spasm. The 
administration of drugs, especially preparations of opium, is not to be 
relied upon. 

In the milder cases the effect of stomach washing and careful feed- 
ing is to bring about a gradual lessening in the vomiting and gastric 
peristalsis, though it is usually some weeks before any material gain 
in weight is seen. Eelapses are not uncommon. 

Surgical Treatment. — Several different operations have been pro- 
posed, but only two have been frequently performed : gastroenterostomy 
and a form of pyloroplasty known as Eammstedt's operation. In the 
latter the circular muscular layer is divided externally without opening 
the stomach. After this is done the pylorus opens and food passes readily 
into the intestine. It is as yet too early to speak finally as to the relative 
value of these two operations; but our observations upon over fifty cases 
treated by the latter operation lead us to prefer it. It requires but 
fifteen or twenty minutes, while gastro-enterostomy requires fully twice 
as much time; it involves much less handling of the abdominal viscera ; ii 
is followed by much less shock; there is less subsequent vomiting; con- 
valescence has been more rapid; fluids pass directly through the natural 



328 DISEASES OF THE DIGESTIVE SYSTEM 

channel, and diarrhea has been seen much less frequently than after the 
other operation. While few of our cases have as yet been followed longer 
than a year and a half, up to the present time all the advantages seem 
to be with this operation. 

The after-treatment is exceedingly important and the outcome de- 
pends almost as much upon this as upon the operation itself. Feeding 
may be begun as soon as the child has recovered from the anesthetic. 
The food, if possible, should be breast milk. By all possible means 
should the mother's milk be conserved. Beginning with one or two 
teaspoonfuls, it may be given every two hours, alternating with the same 
amount of water, the amount being gradually increased and the interval 
lengthened so that the child at the end of forty-eight hours is usually 
taking one ounce of milk every three hours, and the same quantity of 
Water between the feedings. At the end of a week or ten days the infant 
may in most cases be put back to the breast, but the amount taken at 
one time should be limited and the nursing closely watched. In the 
beginning not over one or two minutes' nursing should be permitted. 
Fnless the bowels move freely, from one-half to one teaspoonful of castor 
oil should be given twenty-four hours after operation. The vomiting 
which not infrequently occurs occasionally for one or two days may 
sometimes be relieved by keeping the head of the child's crib consid- 
erably elevated, or supporting him in a semi-sitting posture and by 
putting him over the nurse's shoulder from time to time to enable him 
to get rid of the gas in the stomach, or by the occasional introduction 
of the stomach tube. 

Hypodermoclysis is a procedure of much value, sometimes before 
and nearly always after operation, since these infants are usually suf- 
fering greatly from the lack of water. From 150 to 240 c. c. of a 
normal saline solution may be given, and in bad cases repeated daily 
for three or four days. It is often advantageous to add to the saline 
3 per cent of glucose. 

The shock of operation with most of these patients is surprisingly 
little. With careful feeding favorable cases begin to gain weight within 
a few days after operation and in a few weeks are apparently as well 
as ever. Cases we have followed for three or four, years do not suffer 
subsequently from digestive disturbances more frequently than do othor 
children. 

Opera! ion is to be looked upon not as a last resort in a condition 
well-nigh hopeless, but as offering in the hands of an experienced surgeon 
mii excellent prospect of recovery. The statistics of operation by the 
three American surgeons, Downes, Scudder and Eichter, who have pub- 
lished the largest number of cases, show a mortality of but 28 per cent 
in 122 operations. Of the last 62 consecutive cases operated on in the 



VOMTTTNG 329 



Babies' Hospital, nearly all by Downes, there were 44 recoveries. The 
results of medical and surgical treatment cannot well be compared, for 
they usually refer to quite different groups of cases. 



VOMITING 

Vomiting is one of the most frequent symptoms of disease in infants 
and young children, and occurs from a wide variety of causes. The 
physician must have in mind both its common and its uncommon causes. 
Vomiting takes place with great facility in young infants even from 
slight causes, owing to the position and shape of the stomach. 

1. Vomiting from Overfilling of the Stomach. — This is often seen in 
nursing infants, and there may be no other symptom of disease. It 
comes within a few minutes after nursing, is easy and without effort, 
and the food is but little changed. It may be excited by moving the 
child or making undue pressure upon the stomach, and requires no treat- 
ment except to diminish the quantity of food. Vomiting also comes 
from distention of the stomach with gas, most of it being air which has 
been swallowed with nursing or feeding. It is relieved by placing the 
child in an upright position or over the shoulder before he is put in 
his crib. 

2. Vomiting is almost invariably present in cases of acute gastric 
indigestion and acute gastritis. With the former it does not usually 
come immediately after feeding, and it may be delayed for several 
hours; with the latter it is usually persistent. The vomited matter 
consists of the contents of the stomach, but often mucus, and, in severe 
cases, bile and traces of blood may be vomited for some time afterward. 

3. In the hypertrophic stenosis of the pylorus of early infancy, un- 
controllable vomiting without fever is the principal symptom. (See 
previous Chapter.) 

4. In acute intestinal obstruction vomiting is rarely absent, and in 
most cases it is persistent. In the newly-born, persistent vomiting is 
almost invariably dependent upon congenital obstruction of the intestine, 
which is most frequently in the duodenum. In malformations of the 
colon and rectum it is less constant and appears later. In intussuscep- 
tion, vomiting is forcible, immediately excited by the taking of food, and 
is at first bilious, but later may become fecal. 

5. Vomiting is a frequent and almost a constant symptom of acute 
peritonitis, whether localized or general, of which appendicitis is the 
usual cause. It is then associated with abdominal distention, tenderness, 
and fever. 

G. In certain nervous discuses, especially tumor of the brain and 



330 DISEASES OE THE DIGESTIVE SYSTEM 

acute meningitis, whether cerebrospinal or tuberculous, vomiting is very 
common. Cerebral vomiting is usually forcible or projectile. It may 
have no relation to meals. 

7. In infants, and less frequently in older children, vomiting is onte 
of the most frequent symptoms to mark the onset of acute febrile dis- 
eases especially the beginning of scarlet fever, pneumonia, and malaria. 

8. An accumulation in the blood of various toxic materials may pro- 
voke vomiting; the best known example is uremia. In cyclic vomiting 
it is quite probable that the cause is the accumulation of some toxic 
substance in the blood. The absorption of poisons taken in with milk 
or other food, or developing in the gastro-enteric tract, may excite 
vomiting. In some of these conditions it is possible that the vomiting 
may be eliminative. The cases dependent upon renal disease are dis- 
covered by examination of the urine. The other forms are often exceed- 
ingly obscure, and recognized only by the exclusion of all other causes 
of vomiting. 

9. Vomiting may be reflex from irritation in the pharynx. This is 
frequent in young infants, who may induce vomiting by stuffing the 
fingers into the mouth. In certain cases the irritation from worms in 
the intestinal tract may cause vomiting, and it is possible that even 
dentition may produce it. 

10. Habit is a frequent cause, in cases of chronic vomiting, especially 
in children of a neuropathic constitution. In young infants a habit 
may be acquired of regurgitating the food very much in the manner 
of the ruminating animals. Soon after feeding there is seen a move- 
ment of the mouth and fauces resembling swallowing, then the food 
appears in the mouth and is ejected without force. This may be re- 
peated until a large part of the food taken is lost. The habit once 
formed may continue for months, the nutrition of the infant often 
suffering to a serious degree. To this condition the name rumination 
has been given. It is not difficult of recognition if the infant is closely 
observed after feeding. 

The most successful treatment is the administration of a food so 
thick that it cannot be readily regurgitated by the infant in the manner 
described: e.g., four tablespoons of barley flour is cooked for thirty 
minutes in one pint of whole milk. From one to two ounces are given 
every three or four hours with a spoon, as it is too thick to go through 
a rubber nipple. Water should be given between feedings. Some 
children have the power of vomiting at will anything in the nature of 
I'".). I which they do not like, yet who retain other food without difficulty. 
One such child Mould tolerate large doses of quinin, to which he had 
do aversion, without the slightest disturbance. Habit is a potent cause 
in continuing vomiting when from any cause it has occurred frequently. 



CYCLIC VOMITING 331 

In children who have this habit the most trivial cause will provoke it. 
It may be present without any other sign of gastric disease, and appears 
simply to depend upon exaggerated reflex irritability of the organ. We 
have seen a number of children who up to the third or fourth year 
objected so strenuously to taking solid food that they would imme- 
diately vomit it, no matter of what variety or in how small a quantity, 
although fluids were taken and easily digested. 

11. Chronic vomiting may depend upon habit, as just described, or 
upon chronic indigestion; or it may be associated with chronic pulmo- 
nary disease — vomiting here being excited by the attacks of coughing, at 
first only when the paroxysms are severe, and later even when they are 
slight. 

The diagnosis of a case in which vomiting is the chief symptom 
may be difficult. The first important distinction to be made is between 
cases in which the vomiting is of gastric origin, and those in which it 
depends upon other causes. It is only by a careful consideration of the 
associated symptoms that an accurate diagnosis can be reached. 

The treatment of vomiting is the treatment of the cause upon which 
it depends. 

CYCLIC VOMITING 

This is a frequent condition and up to recent times has attracted 
but little attention except in this country. Although the clinical picture 
is a very clear and definite onej its exact pathology is undetermined. 
It has also been described under the names periodical vomiting and 
recurrent vomiting. It is characterized by periodical attacks of vomit- 
ing, which recur at regular or irregular intervals of weeks or months, 
apparently without any adequate exciting cause. The usual duration 
of the attacks is two or three days, during which all attempts to control 
the vomiting are usually without avail, but at the end of this time it 
generally ceases spontaneously. 

Etiology. — The first attacks are usually seen between the ages of two 
and four years, but they may date back to infancy. The two sexes seem 
to be almost equally liable. A few of the patients are strong children. 
but the great majority are rather delicate and of a highly nervous 
temperament. The cases are seen chiefly in private practice, often 
occurring among those who have the best surroundings. In most cases 
the antecedents of patients are of a neurotic type. The attacks are 
not usually traceable to distinct or flagrant errors in diet, and yet the 
habitual diet seems to bear some relation to the disease. The exciting 
cause is often a nervous one — great fatigue or unusual excitement. 
sometimes a railroad journey or a child's party; in many instances it 



332 DISEASES OF THE DIGESTIVE SYSTEM 

seems to be induced by some minor illness having no relation to the 
digestive tract, such as an attack of tonsillitis or bronchitis. In children 
subject to this condition serious diseases, such as scarlet fever or measles, 
may be ushered in by prolonged and repeated vomiting, which usually 
ceases before the end of the febrile period. General anesthesia, specially 
by ether, is very likely to precipitate an attack. 

Symptoms. — The clinical picture presented by these cases is very char- 
acteristic, and is well illustrated by the history of the following case: 

The patient was a well-nourished boy of six years when he first came 
under treatment. He belonged to a neurotic family, and the attacks 
dated back to infancy. From this time they had recurred usually at in- 
tervals of a few months ; occasionally five or six months would pass with- 
out one. The symptoms in all the attacks were similar in kind, differ- 
ing only in degree. They were preceded by a prodromal period lasting 
from twelve to twenty-four hours, marked by languor, dulness, dark 
rings under the eyes, loss of appetite, and a general sense of discomfort 
in the epigastrium. At this time the temperature was generally slightly 
elevated. The vomiting then began suddenly. It was attended with 
great retching and distress; it was often repeated every half -hour or 
hour for two days. On one occasion it occurred seventeen times in a 
single night. Vomiting was immediately excited by the taking of any 
food or drink, but it occurred also when nothing was taken. The vomited 
matters consisted of frothy mucus and watery material, frequently 
streaked with blood, apparently from the violence of the emesis, and often 
containing bile. The temperature usually fell to about 100° F. when the 
vomiting began, and continued at or below this point throughout the 
attack. By the end of the second day the exhaustion was very marked — 
so severe, in fact, as apparently to threaten life. The child lay in a 
semi -stupor, with eyes half open, lips and tongue dry, rousing at times 
to beg for water. The pulse was rapid and weak, and sometimes slightly 
irregular. There was no distention of the abdomen; it was usually 
flattened. By the third day the vomiting became less frequent and 
then ceased entirely. Convalescence was rapid, and by the end of the 
week the boy was almost as well as usual. The attacks continued to 
recur at gradually lengthening intervals until they finally ceased alto- 
gether at about the twelfth year. 

A great number of these cases come under observation. The usual 
duration of the attacks is one to three days. In one child they lasted 
regularly for five days. Occasionally a severe attack will last a week. 
The average number of attacks is four or five a year. 

Prodromal symptoms are present in most of them — headache, gen- 
eral languor, coated tongue, and anorexia are the most frequent; in 
some there is marked constipation, with a history of very white stools 



CYCLIC VOMITING 333 

for some time. But it is not uncommon for an attack to occur in the 
midst of apparently perfect health. The tongue is usually coated at the 
beginning of an attack, and at its height it is often dry and brown. The 
abdomen seems empty and its walls sunken ; pain and tenderness are 
both rare. The bowels are usually constipated and move only with diffi- 
culty by artificial means. Very exceptionally there may be diarrhea 
with foul stools. 

There is, as a rule, no desire for food, but the continual cry is 
for water to quench the constant, burning thirst. The pulse after the 
second day becomes rapid, soft, and often somewhat irregular. The 
respiration is shallow, and at times this also may be irregular. The 
temperature is usually under 100.5° F., rarely it may be 102° or 103° F. 
The low temperature is a point of much diagnostic value. The patients 
are dull, apathetic, and wish to be left alone. Headache is very common. 

The disposition to vomit is sometimes so great that patients are 
afraid to move or even to talk lest it may be provoked. The vomited 
matter is often large in amount, considering that the patient is fasting. 
It is essentially gastric juice, containing free HC1, mucus, serum, many 
epithelial cells, and often traces of blood. Less frequently vomiting may 
occur only two or three times a day. The urine is concentrated, and 
frequently contains at the height of the attack a trace of albumin, a few 
hyaline casts, and some blood cells. An increase in the renal secretion 
may be the first sign of improvement. There is usually an excess of 
indican both during and between attacks. A condition practically con- 
stant, and first pointed out by Marfan, is the presence in the urme of 
acetone, diacetic and /? oxybutyric acids. These substances often appear 
in the urine in large amounts so early in the attack that they can not be 
ascribed to starvation, and therefore may be of diagnostic value. How- 
ever, it should be emphasized that acetonuria is not the same as acidosis ; 
the latter is uncommon in cyclic vomiting, but occurs in a severe form. 

The Nature of the Attacks. — These cases have little in common with 
the ordinary attacks of indigestion. With our present knowledge they 
are to be regarded as explosions due to faulty metabolism. They have 
much in common with attacks of migraine which in later life nol infre- 
quently replace the attacks of vomiting. The studies of Hilliger upon a 
child subject to attacks of cyclic vomiting showed an interesting reaction 
to the withdrawal of carbohydrates. When the carbohydrates in the diel 
were greatly restricted the blood sugar fell at once to one half the normal 
amount and vomiting was precipitated. Normal children were not influ- 
enced by the temporary withdrawal of carbohydrates. 

Prognosis. — Although these patients very often seem to he most 
alarmingly ill, the danger to life is slight. We have seen l>ui three fatal 
cases, and in one the diagnosis is open to question, as no autopsy could 



334 DISEASES OF THE DIGESTIVE SYSTEM 

be obtained. Griffith reports two fatal cases, the autopsy in one showing 
nothing definite. The probabilities are always in favor of a recur- 
rence of the attacks. In most of the patients who have been observed 
they have extended over a series of several years, although by a careful 
regimen much may be done to reduce their frequency and diminish their 
severity. In a considerable proportion of cases they may be stopped alto- 
gether. Toward puberty there appears to be a strong tendency to spon- 
taneous recovery. 

Diagnosis. — Organic disease of the brain and kidneys must first be 
excluded. The first attacks witnessed may strongly suggest the onset of 
tuberculous meningitis ; and only the course of the symptoms may show 
that this is not present. Usually a history of many previous attacks 
may be obtained. From acute indigestion, cyclic vomiting is differen- 
tiated by the fact that the attacks are not brought on by indigestible 
food, and also by the persistence of the vomiting, and the early presence 
in the urine of the acetone bodies. It is distinguished from gastritis by 
its severity, the shorter duration of its symptoms, and its self-limited 
course. 

Appendicitis is excluded by the absence of pain, tenderness, and mus- 
cular rigidity; intussusception by the fact that the symptoms are less 
severe, by the absence of blood and mucus from the stools, and by the 
fact that intussusception is usually seen in infancy. 

Treatment — When the premonitory symptoms appear, starvation and 
free purgation offer the best prospect of aborting an attack. If the 
vomiting has. once begun, nothing seems to have the slightest influ- 
ence in controlling it. It is usually increased by the taking of food or 
drink or by any medication by the mouth, and all should be withheld. 
The patient should be kept absolutely quiet and a saline solution given, 
per rectum, at regular intervals, usually six to eight ounces, four or five 
times a day. To this twenty or thirty grains of sodium bicarbonate may 
be added. This keeps up the urinary secretion, allays thirst and often 
restlessness, and when it is retained usually adds much to the patient's 
comfort. When the vomiting has ceased for several hours it is not likely 
to recur if food is very judiciously administered, at first in small quan- 
tities. Broth, thin cereals, kumyss, or small quantities of iced milk and 
lime-water in equal proportions may then be given. In severe or pro- 
longed cases, six to eight ounces of a 5-per-cent glucose solution may be 
given by rectum once or twice a day. If this is not retained, three to six 
ounces may be given subcutaneously in a saline solution. 

When acidosis develops it should receive its special treatment. (See 
Acidosis.) Between the attacks, the alkaline treatment is to be recom- 
mended; it consists in giving bicarbonate of soda in doses of fifteen to 
thirty grains three times daily and continuing it for many months. 



ACUTE GASTRITIS 335 

When the prodromal signs of an attack appear, larger doses, as much as 
twenty grains every hour, should be administered. The diet should con- 
sist principally of meat, vegetables, skimmed milk, cereals in moderate 
amount, and stale bread. In addition to careful regulation of the diet the 
general nutrition should be considered, and the patient's life so regulated 
that extreme fatigue and exhaustion, as well as nervous excitement, are 
prevented. In most cases close attention to these matters has resulted 
in a very great diminution in the frequency of the attacks. 



' ACUTE GASTRITIS 

In comparison with the frequency of inflammatory diseases of the 
intestine, those of the stomach are rare, particularly so in infancy. 
Owing largely to the character of its secretion and its contents, the stom- 
ach is much more resistant to infection than are the intestines. Gastritis 
seldom exists alone, but is usually associated with enteritis or colitis. 

Etiology. — The causes of gastritis are, in the main, those of acute 
gastric indigestion — improper food or feeding — to which possibly is 
added infection. Gastritis may also be caused by the introduction of 
irritants, which may either be swallowed accidentally or given as drugs. 

Lesions. — The mucous membrane of the stomach may be the seat of 
acute catarrhal, ulcerative, or membranous inflammation, all forms ex- 
cept the catarrhal being rare. There is also seen a mixed form, which 
from its cause is usually termed "corrosive" gastritis. 

Catarrhal Gastritis. — This is characterized by hyperemia of the mu- 
cous membrane, exudation of cells into the mucosa, .a great increase 
in the secretion of the mucous glands, and changes in the epithelium. 
About the only change which can be recognized by the naked eye is 
congestion and swelling of the mucous membrane. These are usually 
more marked toward the pyloric end and along the greater curvature. 
There may be small extravasations of blood into the mucosa. The stom- 
ach contains undigested food and mucus, which may be thick and tena- 
cious, adhering very closely to the mucous membrane. The mucus may 
be stained brown from the capillary hemorrhages. The stomach may be 
either distended or contracted. Under the microscope the changes are 
seen to be almost entirely in the mucosa. In some places there is loss of 
the superficial epithelium, in others only degenerative changes in it are 
seen. The mucosa is infiltrated with round cells, this process being 
rarely diffuse, but generally occurring in patches. The blood-vessel- are 
distended and many small extravasations are seen. Sometimes I here is 
a moderate infiltration of the submucosa. Acute catarrhal gastritis 
alone is rarely severe enough to cause death. It Is usually seen in cases 



336 DISEASES OF THE DIGESTIVE SYSTEM 

which prove fatal from other causes, particularly diseases of the intestine. 

Gastric softening (g astro malaria) is a condition dependent upon 
post-mortem changes — probably self -digestion of the stomach. It is 
found both where gastric symptoms were present and where they were 
absent. It is situated nearly always in the posterior wall, and usually 
covers a considerable area, about one-third or one-fourth of this wall. It 
is recognized by the gelatinous, translucent appearance of the walls of 
the stomach, which are so softened that the finger may be pushed through 
them without force, or that sometimes the stomach ruptures while it is 
being removed. This condition is rarely seen when the stomach is empty. 
It can scarcely be mistaken for a pathological condition if its occurrence 
is borne in mind. 

Ulcerative Gastritis. — This was met with six times, not including 
tuberculous cases, in 390 consecutive autopsies upon infants in the 
Babies' Hospital. Three of the patients were less than four months old, 
and all were females. The ulcers varied from one twenty-fifth to one 
quarter of an inch in diameter, and usually from ten to fifty were pres- 
ent. They seldom extended to the muscular, and never to the peritoneal 
coat. The lesion was most marked in the posterior wall, toward the 
pyloric end and along the greater curvature. Evidences of catarrhal in- 
flammation were present in most of the cases, and in four, of mem- 
branous inflammation. Lesions in some other part of the digestive tract 
.were present in all but one case, in two there w r as thrush in the esopha- 
gus; in three there was ulceration somewhere in the intestines. 

Membranous Gastritis.- — This is even more rare than the varieties 
previously mentioned. We have met with it but four times in infants. 
One case was associated with a membranous colitis; a second case with 
a streptococcus inflammation of the fauces and larynx in an infant but 
six weeks old. The esophagus was not involved in this case ; and indeed 
it often escapes. No Klebs-Loeffler bacilli could be found either in cover- 
slip preparations or by culture. 

To the naked eye the membrane appears of a grayish-green color; 
it is adherent, but can be detached in quite large patches. Only a por- 
tion of the stomach is usually affected. The microscopical appearances 
resemble those of membranous colitis. There is a pseudo-membrane com- 
posed of fibrin, granular matter, epithelial cells, and bacteria. The 
mucosa shows a moderately dense infiltration with round cells, and in 
places superficial ulceration. There is also infiltration of the submucosa, 
and in some places even the muscular coat is involved. 

Membranous gastritis occurring in patients dying of diphtheria is 
nol common. Councilman, Mailory, and Pearce noted its presence in 
only five of one hundred and twenty-seven autopsies. 

Corrosive Gastritis (toxic gastritis). — This form of inflammation is 



ACUTE GASTRITIS 337 

excited by various irritating and caustic substances, taken by accident. 
The most frequent are carbolic acid and caustic alkalis. 

The lesions in the stomach depend upon the amount of the substance 
swallowed, the degree of concentration, and whether the stomach was 
full or empty at the time. Strong caustics, whether acids or alkalis, 
usually act more deeply and extensively in the pharynx and esophagus. 
for, owing to the spasmodic contraction of the muscles of these parts, 
often but a small amount of the substance reaches the stomach. Concen- 
trated irritant poisons produce in the stomach, especially along the 
greater curvature, irregular ulcers, which may be so deep as to cause per- 
foration, or they may affect the mucous membrane only. In severe cases 
death takes place early, often in a few hours. Dark, ragged ulcers are 
found in the stomach, the surrounding mucous membrane is the seat of 
intense congestion, and in places there are extravasations of blood. If 
death is delayed there are evidences of intense inflammation, sometimes 
with the production of a pseudo-membrane. If the amount of poison is 
not sufficient to cause death, and if the patient recovers from the re- 
sulting gastritis, a cicatricial condition of the stomach results, which 
later may lead to stenosis of the pylorus or other deformity of the 
organ. 

Symptoms. — Catarrhal gastritis can not be distinguished at its begin- 
ning from an attack of acute indigestion. There is fever, pain, vomit- 
ing, thirst, loss of appetite, coated tongue, and prostration. The pres- 
ence of inflammatory changes is indicated by the continuance of these 
symptoms, particularly the pain, vomiting, fever, and thirst. With the 
pain there may be epigastric tenderness. All food and liquids are im- 
mediately rejected, and even when nothing is taken the retching and 
vomiting may continue, nothing but frothy mucus or serum being 
brought up, sometimes streaked with blood. The vomited matters are 
usually very sour; they may be bilious. The temperature is rarely high 
except at the outset. After the first or second day it usually ranges 
between 100° and 101.5° F. Thirst is intense, and all liquids are taken 
with avidity, especially if cold, even though they are immediately 
vomited. The tongue is thickly coated with a white fur, and the breath 
may be foul. The constitutional symptoms are generally most severe al 
the outset. The usual duration of such attacks is from four to seven 
days, but with improper management, especially injudicious feeding, 
the disease may be much prolonged. One attack may follow another 
until a chronic condition is established. In most of the cases there is 
some disturbance of the intestines, usually a sharp attack of diarrhea. 
Sometimes the gastric symptoms subside after a few days and those of 
the intestines become the predominant ones. The symptoms above given 
are those in infancy. In older children there is less fever, prostration, 



338 DISEASES OF THE DIGESTIVE SYSTEM 

and diarrhea, but pain and vomiting are prominent. The attacks are 
usually shorter and altogether less severe. 

The rare cases of ulcerative gastritis have nothing by which they 
can be distinguished from the form described, except a more prolonged 
course and a greater liability to hemorrhage. 

Membranous gastritis also presents no peculiar symptoms. In fact, 
in the cases we have personally seen, the gastric symptoms were insig- 
nificant, and the condition not suspected during life. 

In corrosive gastritis the effects of the caustic may be seen in the 
mouth and pharynx, the mucous membrane being usually of a gray or 
whitish color. Pain and a sense of constriction are felt in the esophagus 
and stomach, and thirst is great. Vomiting follows almost immediately, 
and the matters vomited are usually bloody. The subsequent course in 
most of the cases is the rapid development of collapse, and death in a 
few hours from shock. The younger the child the sooner does the case 
terminate. In irritant poisoning not severe enough to produce death, 
the symptoms of acute gastritis follow, usually accompanied by more or 
less enteritis owing to the passage of the irritant into the intestine. 
There is seen a continuance of the vomiting, pain and epigastric disten- 
tion, and diarrhea, and from these symptoms death may result in two 
or three days. It is extremely rare in early childhood for the patient to 
survive both the stage of shock and that of acute inflammation, so that 
the deformities of the stomach and the chronic conditions mentioned are 
practically never met with except in older children. 

Treatment. — Cases of acute catarrhal gastritis are to be managed very 
much like those of acute gastric indigestion. Thirst may be relieved by 
swallowing bits of ice. Where there is continuous vomiting of acid 
mucus, relief is sometimes afforded by repeating the stomach-washing 
once in twelve hours with a one-per-cent solution of bicarbonate of soda, 
at 110° F. In older children, beneficial results sometimes follow the 
use of bismuth subcarbonate (gr. x every two hours) ; but in infants 
we have seen but little effect from any form of medication, the reliance 
being upon rest, careful feeding, and stomach-washing. 

Cases of corrosive gastritis require special treatment. The first indi- 
cation is to administer the proper chemical antidote to the substance 
swallowed, and the next to use bland mucilaginous or oily fluids, such 
as milk, albumin water, oils in large quantities, etc. Especially should 
stomach-washing be avoided except immediately after the ingestion of 
the poison. Opium is always required, on account of pain, and should 
be given hypodermically. The general symptoms are to be treated 
according to the indications of the individual case. 



CHRONIC GASTRIC INDIGESTION— CHRONIC GASTRITIS 330 



CHRONIC GASTRIC INDIGESTION— CHRONIC GASTRITIS— GASTRIC 

CATARRH 

Although from a pathological point of view these conditions may not 
be identical, from a clinical standpoint there is no advantage in attempt- 
ing to separate them. Nothing distinguishes chronic indigestion from 
chronic gastritis except that in the latter, in addition to continued de- 
rangement of function, there is a greater increase in the production of 
gastric mucus. Chronic indigestion does not long exist without the 
production of a certain amount of catarrhal inflammation. This con- 
dition in the stomach seldom, if ever, exists without more or less involve- 
ment of the intestine, and in the majority of cases the intestinal condi- 
tion is the more important. In some, however, the gastric symptoms 
predominate, and it is only those which are here considered. What is 
often called chronic gastric indigestion in infancy has already been dis- 
cussed in the chapter devoted to Difficult Feeding. In this connection 
only the condition as it affects older children will be referred to. 

Etiology. — Chronic gastric indigestion may follow acute attacks, or 
it may be chronic from the outset. Etiological factors of importance are 
overfeeding, too large meals, unsuitable food, especially solid food too 
early and in too large amounts for very young children. The condition 
generally accompanies dilatation of the stomach. As a consequence of 
imperfect digestion, fermentation in the residuum takes place, and the 
irritating products of this fermentation soon cause a catarrhal inflamma- 
tion with a production of mucus. Chronic gastric indigestion also com- 
plicates many of the constitutional diseases of childhood, especially 
rickets, syphilis, tuberculosis, and malnutrition. It may follow any of 
the acute infectious diseases. In older children it is often due to the 
habit of rapid eating and insufficient mastication, the cause of which is 
very often carious teeth. It may complicate valvular disease of the 
heart. 

Lesions. — The changes found in chronic gastritis are usually confined 
to the mucosa. In the mild form there are degenerative changes of the 
epithelium of the tubules, with an increased production of mucus; there 
may be a slight infiltration of the mucosa with round cells. The more 
severe form, with marked cell infiltration and the production of new 
connective tissue, is extremely rare. The submucous coat may be thick- 
ened and the muscular coat attenuated. The lesion can not be recognized 
by the naked eye. The stomach is apt to be more or less dilated, and its 
surface is coated with thick and very adherent mucus. This lesion rarely 
exists alone, practically never in infancy, but is associated with similar 
lesions in the intestines, the latter often being more severe. 



340 DISEASES OF THE DIGESTIVE SYSTEM 

Symptoms. — In all cases the most constant symptom is vomiting, 
which may occur regularly after meals, or only in the morning before 
breakfast. If the latter, the vomited matters consist chiefly of mucus. In 
addition to these regular attacks there may be the frequent regurgitation 
of small quantities of food. There are present gastric flatulence and 
pain, due to hyperacidity or to acid fermentation. The appetite is vari- 
able — sometimes inordinate, sometimes entirely lost; it may be capricious, 
there being usually a craving for highly seasoned food. The tongue is 
constantly furred, and the breath usually disagreeable. These symptoms 
are seen in all degrees of severity. Intestinal disturbances are not fre- 
quent. Constipation is more common than diarrhea. The general symp- 
toms are those of malnutrition. There are anemia, wasting, constant 
fretfulness, disturbed sleep, and various other nervous disorders. 

Prognosis. — The prognosis depends upon the age of the patient, the 
duration of the disease, the surroundings, and upon how well treatment 
can be carried out. There is little tendency to spontaneous recovery, but 
under favorable conditions, with constant care, much may be done for 
all these patients and many of them may be completely cured. 

Treatment. — The general treatment is too apt to be ignored, but it is 
just as important as measures directed more specifically to the stomach. 
A large, roomy nursery, and plenty of fresh air by night and by day, 
are very important; equally necessary are quiet surroundings and free- 
dom from disturbing conditions which sometimes obtain in the nursery. 
General friction of the body is useful in delicate children with poor cir- 
culation. Of the measures directed to the stomach, two are chiefly to be 
depended upon — stomach-washing and proper feeding. 

Stomach-washing is useful, first, in removing the mucus which is 
abundant in most of these cases; secondly, in cleansing the organ thor- 
oughly at least once a day, this of itself being most important ; thirdly, 
as a stimulant to the gastric secretions, especially hydrochloric acid. 
Plain boiled water, or a weak alkaline solution — sodium bicarbonate, one 
dram to the pint — may be employed. In the early part of the treat- 
ment the washing should be done daily ; later, every second or third day. 
The time selected is not very important, but it is better to make this 
about three hours after feeding. 

With some children stomach-washing can not be easily employed, and 
oilier means must be used to clear the stomach of mucus. The best is 
undoubtedly the use of large draughts of water, as hot as can be borne, 
mii hour before eating. From six to eight ounces should be taken, pre- 
ferably slowly by sipping. To this may be advantageously added, in 
many eases, fifteen or twenty grains of bicarbonate of soda. 

The diet should consist of diluted skimmed milk, whey, buttermilk, 
kumyss or xoolak, beef juice, rare meat, and a moderate amount of 



DILATATION OF THE STOMACH 341 

starchy food, preferably dried bread or zwieback. All fruits should be 
avoided. All pastry, sweets, nuts, and candies should be absolutely pro- 
hibited. With improvement in the symptoms green vegetables may be 
added to the diet, and the amount of starchy food increased. The amount 
of water taken at meal-time should be carefully restricted. Beneficial re- 
sults are often obtained in these cases by the nse of nux vomica or sim- 
ple bitters before meals, and the regular administration of hydrochloric 
acid (gtt. v to viij of the dilute acid) shortly after meals. The general 
treatment must not be neglected. The patient should lead an out- 
door life as much as possible, and should take regular but very moderate 
exercise. Great caution is necessary against overfatigue. Iron may be 
given in most cases during convalescence; but cod-liver oil should be 
carefully avoided until the gastric symptoms have quite disappeared. 
Eelapses are easily excited, and the most constant care regarding the 
food must be maintained for months, or even years. 



DILATATION OF THE STOMACH 

Moderate dilatation of the stomach is quite a frequent condition, 
although it is not so large a factor in the disorders of digestion in 
infancy and childhood as many who have written upon the subject 
would lead us to believe. A very marked degree of dilatation is rare, 
but in these cases its recognition is important and its treatment difficult. 

Dilatation is almost invariably regular or cylindrical; it is usually 
most marked at the cardiac extremity. Cases of irregular or saccular 
dilatation, except when associated with cicatricial conditions, are of 
very rare occurrence. 

Dilatation may also result from congenital stenosis of the pylorus. 
The most important predisposing cause, however, is the muscular atony 
which accompanies rickets. It is found to a slight degree in almost all 
severe cases of rickets. The principal exciting causes are continued 
distention from overfeeding and chronic indigestion. 

In most cases the only symptoms are those of the chronic indigestion 
which almost invariably accompanies dilatation. The vomiting seen 
with dilatation is peculiar in that it is infrequent, possibly only once a 
day, but then the quantity vomited is larger than the last meal taken. 
In young infants the pressure symptoms resulting from acute dilatation 
may be very serious. This is particularly true of those with acute bron- 
chitis or bronchopneumonia, or atelectasis. In such patients we have 
seen very grave symptoms accompany the rapid distention of a dilated 
stomach, and in one very delicate infant of three months this was appar- 
ently the cause of death. A positive diagnosis of dilatation is only 



342 DISEASES OF THE DIGESTIVE SYSTEM 

made by the physical signs. There is epigastric fulness and distention, 
and in some thin patients the outline of the stomach can be distinctly 
seen. Dilatation of the transverse colon, however, may be mistaken for 
dilatation of the stomach. In the latter, the lower outline is convex, 
while in the former it is usually slightly concave. The most satisfactory 
means of diagnosis is by percussion. The examination should be made 
three or four hours after feeding, at which time the whole abdomen is 
apt to be tympanitic. The stomach should then be filled with water; 
the lower limit of the area of flatness will be the lower border of 
the stomach. This is much more satisfactory than determining the out- 
line alter the generation of gas in the stomach. If the lower border 
comes below the umbilicus, it may be assumed that the stomach is 
dilated. 

In moderate dilatation of the stomach the prognosis is good unless 
due to pyloric stenosis. If the infant has any acute or chronic pulmo- 
nary disease, dilatation of the stomach may add to the discomfort and 
even to the danger from that condition. The distention of a dilated 
stomach occurring in the course of any acute pulmonary disease should be 
relieved by the use of the stomach tube. 

In the management of these cases the first point is to restrict the 
use of fluids, reduce the size of the meals, and regulate the diet in 
accordance with the general plan outlined in the chapter on Chronic 
Indigestion. If the dilatation is marked, the stomach should be washed 
once a day. The general condition of the patient usually requires tonics. 
Rickets, if present, should receive its appropriate constitutional treat- 
ment. 

ULCER OF THE STOMACH 

Ulceration of the stomach may be found in connection with several 
pathological processes which are quite distinct from one another : 

1. Ulcers in the Newly Born. — These have already been referred to in 
the chapters on Hemorrhages of the Newly Born. The only character- 
istic symptom is hemorrhage. 

2. Ulcers Resulting from Acute Gastritis. — These also are not fre- 
quent. As a rule they give no symptoms except those of gastritis, 
although in several cases we have known severe hemorrhage to result 
from them. This symptom will be considered later. 

3. Tuberculous Ulcers. — These are quite rare. We met with gastric 
ulcers five limes in one hundred and nineteen autopsies on tubercu- 
lous eases; however, the evidence was not conclusive in all of them 
that the fleers were tuberculous; but in three the tubercle bacilli were 
found. Usually there were several small .ulcers; in one case but two 



DUODENAL ULCER 343 

were present, the larger one being nearly three-fourths of an inch in 
diameter, and situated on the posterior wall near the middle of the 
greater curvature. All but one of these cases were in infants, one child 
being only ten months old. The ulcers gave no symptoms during life, 
and death took place from general tuberculosis. This is the history of 
nearly all the few cases on record. In one, however, reported by Casin, 
a tuberculous ulcer perforated the stomach and caused death from peri- 
tonitis. 

4. Simple Perforating Ulcers. — In young children these are of great 
rarity and uncertain pathology. Eotch has reported a case in an infant 
but seven weeks old, and Cade one in an infant of two months. 

The symptoms of ulcer before perforation are gastric pain and ten- 
derness, vomiting of blood, and often bloody stools. In most of these 
cases in children there were no symptoms until perforation; then fol- 
lowed collapse, sometimes high temperature, the rapid development of 
tympanites, and death from shock or from peritonitis. 

The prognosis is bad in all forms of ulcer of the stomach, except the 
small follicular variety. In this, however, the diagnosis can not posi- 
tively be made except by gastric hemorrhage, and it is only this which 
makes these cases serious. 

Treatment. — The treatment is absolute rest, ice by mouth, small doses 
of opium, and rectal feeding ; later, bismuth, arsenic, or nitrate of silver. 
If symptoms of perforation occur the abdomen should be opened without 
delay, as offering the only chance of recovery. 



DUODENAL ULCER 

Until recently these ulcers have been considered very rare in infancy 
and early childhood, but the increasing number of cases reported, espe- 
cially since 1908, indicates that it has formerly been overlooked. From 
a study of ninety-five cases in infants under one year collected from the 
literature by one of us in 1913, the conclusions which follow have been 
drawn. 

Duodenal ulcers are much more common than gastric ulcers; accord- 
ing to Entz they outnumber them ten to one. Not a single instance of 
peptic ulcer of the stomach in infancy has been observed at the Babies' 
Hospital in twenty-seven years. In but one case were duodenal ami 
gastric ulcers found in the same patient, even including cases occurring 
in the newly born. Seventy per cent of the reported cases have been ob- 
served between the ages of six weeks and five months; about ten per cent. 
occur in the newly born. The great majority of the cases have been - 
in infants of the marasmus (atrophic) type. In most of them there 



344 DISEASES OF THE DIGESTIVE SYSTEM 

has been also a history of previous digestive disorders. In several cases 
duodenal ulcers have been associated with spasm of fne pylorus. 

The most frequent site of the ulcer is on the posterior wall of the duo- 
denum and practically all are above the papilla. When but a single ulcer 
is present, as is true of about two-thirds of the cases, it is nearly always 
situated just below the pyloric ring. These ulcers are circular in shape; 
they have shelving, sharply denned edges, usually described as "punched- 
out" in appearance. At the base, blood vessels of considerable size are 
often seen. They may involve the mucous membrane only, in which case 
they may readily be overlooked, or they may go to the muscular coat, to 
the peritoneum or they may even perforate. Microscopical examination 
shows almost complete absence of round-cell infiltration and other 
evidence of inflammatory reaction. The rest of the duodenum usually 
shows a normal mucous membrane or one simply blood stained. Large 
clots or fresh blood may be found in the duodenum or in any part of the 
small or large intestine. The stomach also may contain old or fresh blood. 

The generally accepted view of the pathogenesis of duodenal ulcers 
is that they are due to thrombosis followed by self-digestion of the mucous 
membrane over a circumscribed area. The situation of the ulcers, above 
the papilla, indicates that the lesion is due to the action of the gastric 
juice. Below the opening of the common duct the bile and pancreatic 
juice apparently protect the mucous membrane. 

Symptoms. — In over one-third of the recorded cases no symptoms 
suggestive of the condition were present, the ulcer being found at au- 
topsy in patients dying from other causes. In other cases death occurs 
suddenly in collapse, sometimes preceded by symptoms of an ordinary 
gastro-intestinal disturbance and sometimes by none at all. In such cases 
the autopsy frequently discloses severe concealed hemorrhage or perfora- 
tion. If life is prolonged peritonitis may follow, but its recognition 
under these circumstances is exceedingly difficult since vomiting, fever 
and distention may all be wanting. Localized pain or tenderness in 
patients of this age is of no assistance to the diagnosis, though valuable 
symptoms in older children. The only definite symptom pointing to duo- 
d nal ulcer is hemorrhage. Blood maybe vomited or passed in the stools. 
I n sixty-lour cases of ulcer reported with good histories, bloody stools were 
observed in twenty-eight, bloody vomiting in ten and both in six cases, 
four of these being in the newly born. Clear blood may be seen or blood 
changed by the action of the stomach or intestine. Once it occurs, 
hemorrhage is apt to continue until the death of the patient, usually in 
twenty-four to thirty-six hours. The appearance of blood in any consid- 
erable amount in the stools of a young infant should always suggest duo- 
denal ulcer. .Jaundice was a symptom in but one case in the series. 

The diagnosis is made mainly by the presence of hemorrhage from the 



HEMORRHAGE FROM THE STOMACH 34.3 

stomach or intestine, usually associated with collapse. Perforative peri- 
tonitis may be due to appendicitis as well as ulcer and both intestinal 
hemorrhage and collapse may occur with intussusception. These should 
be borne in mind as two conditions which may be confounded with duo- 
denal ulcer. Polypus and colitis must also be excluded. The prognosis 
of duodenal ulcer at present is very bad. The finding of healed ulcers 
at autopsy proves that recovery does sometimes take place, but it must be 
considered rare. 

The treatment is purely symptomatic: on account of the present un- 
certainty of diagnosis, surgical measures are rarely justifiable. 

TUMORS OF THE STOMACH 

Although exceedingly rare, tumors of the stomach occur in child- 
hood, and are seen even in infancy. A case of sarcoma of the stomach in 
a child of three and a half years has been reported by Finlayson. It was 
apparently primary. The microscopical examination showed it to be of 
the spindle-celled variety. This writer could find no other recorded 
case under the age of fifteen. 

Lymphadenoma of the stomach in a rachitic infant of eighteen 
months has been recorded by Kolleston and Lathan. There were mul- 
tiple tumors arising from the mucous membrane in the pyloric region. 
The case in many features resembled leukemia. 

Six cases of cancer of the stomach in children under ten years arc 
collected in an article by Osier and McCrae. Four of these were in 
young infants and probably congenital. One case, in a child of eight, 
presented the usual symptoms and lesions of the adult disease. 



HEMORRHAGE FROM THE STOMACH (Hematemesis) 

The most frequent variety of hemorrhage from the stomach, that 
is seen in the newly born, has already been considered. 

Serious and even fatal cases of gastric hemorrhage though extremely 
rare may be seen in older infants. The source of the bleeding may be 
small capillary hemorrhages from the mucous membrane, it may be 
from single or multiple ulcers of the stomach or more frequently from 
duodenal ulcers. 

Hemorrhages from the stomacrH*may occur in purpura, hemophilia, 
scurvy, and rarely in malaria. Tn young girls about puberty it may be a 
form of vicarious menstruation. Occasionally blood may be vomited in 
cases of hemorrhagic measles. Two cases are reported in which fatal 
hemorrhage followed the swallowing of a foreign body. In both, vomit- 



346 DISEASES OF THE DIGESTIVE SYSTEM 

ing of blood occurred long after the original accident. In one case two 
and a half years had elapsed. The autopsy in this case showed impac- 
tion of the foreign body and ulceration into the arch of the aorta. Spu- 
rious hemorrhages may occur when blood has been swallowed and then 
vomited. The source of this is most frequently the nose or pharynx. 
It may happen in infants at the breast, when the blood is drawn from 
a fissure or ulcer in the nipple. The amount of blood vomited under 
these circumstances may be large enough to be quite alarming. It may 
be recognized by the child's general condition being normal, and by the 
presence of fissures or ulcers upon the nipple. It may sometimes be 
noticed that the vomiting of blood follows nursing from one breast and 
not from the other. 

Symptoms. — There may be no symptoms except those of internal 
hemorrhage, but this is rare. Usually there is vomiting of blood, and 
blood appears in the stools. If the hemorrhage is rapid and vomiting 
speedily occurs, the blood may be of a bright-red color. If it has been 
long in the stomach it is of a dark-brown or black color resembling 
coffee-grounds. The stools containing blood from the stomach are 
black and tarry in appearance. The general symptoms will depend upon 
the amount of blood lost. 

In a case where blood is vomited, the first point is to distinguish spu- 
rious from true gastric hemorrhage. The nose and pharynx, especially 
its posterior wall, should be carefully examined. If the child is at the 
breast, the nipples should be examined. In older children it is important 
to distinguish vomiting of blood from hemoptysis. This distinction is 
to be made in accordance with the rules laid down in text-books on gen- 
eral medicine. The prognosis is bad if the hemorrhage is due to ulcer, 
if it is very profuse, or if it occurs in young infants. When it occurs in 
connection with constitutional diseases the prognosis depends upon the 
original disease. 

Treatment. — Altogether the most efficient remedy is the suprarenal 
extract. It may be given very freely, at least two grains every half hour 
to a child of one year. The patient should be kept quiet, preferably upon 
the back; if there are signs of collapse, stimulants may be given hypo- 
dermically or by the rectum. No food or water should be given by the 
stomach for at least twenty-four hours after the hemorrhage has ceased. 



THE SWALLOWING OF FOREIGN BODIES 

Between flic ages of one and four years the habit of swallowing for- 
eign substances is a very common one. The variety of objects swallowed 
includes all those articles which the young child can reach and put into 



THE SWALLOWING OF FOREIGN BODIES 347 

his mouth* The most common are detached parts of toys, marbles, peb- 
bles, buttons, and coins. Not only are such smooth articles swallowed, 
but also with equal readiness, sharp ones, such as pins of every variety, 
bits of glass, fragments of bone, nails, and small toy knives and forks, 
etc. At the time of swallowing, choking attacks, severe pharyngeal pain, 
and sometimes slight hemorrhage may occur. Symptoms referable to 
the esophagus are very few. Nor in the stomach are symptoms often 
excited. While passing through the intestine there may be colicky pains. 
but in the majority of instances there are no symptoms whatever even 
with sharp or angular bodies. Impaction and perforation, while pos- 
sible, are surprisingly rare. The usual time required for a foreign body 
to traverse the intestinal tract is from four to ten days, but it may be con- 
siderably longer. If the body swallowed is a smooth one, it passes the 
sphincter ani without difficulty. But with sharp bodies there may be 
severe pain and sometimes hemorrhage. 

The diagnosis is often a matter of much difficulty, and without an 
X-ray examination a positive diagnosis is impossible. Yery often when 
the physician is called because this condition is suspected by parents the 
alarm turns out to be a false one. 

It is most surprising to see the size, variety, and dangerous character 
of the foreign bodies which pass through the intestinal tract without 
causing any symptoms whatever. The expectant treatment is therefore 
by all means to be recommended. Xo emetics or cathartics should be 
administered. The diet should be abundant and composed of articles of 
food which leave much residue, e. g., coarse cereals, bread, and vegetables. 
Most of all, operation should not be performed or even considered unless 
there are definite local symptoms. 

Quite distinct from such accidental swallowing of foreign substances 
as has just been described, is the practice of pulling off and swallowing 
fur from rugs, wool from toys or blankets, shreds from clothing, and a 
great variety of other substances. This habit is usually seen in nervous 
children, and often in those where some gastric irritation seems to excite 
an abnormal craving. In infants the quantity of the substance is gen- 
erally small and usually it provokes vomiting or the material is speedily 
passed by the bowel. In the Babies' Hospital a colored child of about 
eighteen months passed in one day a large mass of hair which she had 
pulled from her own head. Another child in the same ward pulled into 
shreds and swallowed a large portion of the fool of a cotton stocking, and 
passed the same by the bowel the following day. Such occurrences are 
not very common. 

It occasionally happens that the substance swallowed does not pass 
the bowel but forms an intestinal tumor which may give rise to obscure 
and sometimes to severe symptoms of long duration. But more often the 



348 DISEASES OE THE DIGESTIVE SYSTEM 

tumor forms in the stomach. These gastric tumors are usually composed 
of hair from the patient's own head. They are more frequently seen in 
older children than in infants, and usually in girls on account of the long 
hair. Many of these patients are of the nervous type. The habit may 
continue until a tumor of considerable size may form, sometimes attain- 
ing two or three pounds in weight. 

The symptoms of hair ball in the stomach are vague until the tumor 
is discovered. There are usually gastric disturbances of a rather in- 
definite character. Epigastric pain is common, but vomiting is not 
especially marked. The general health may suffer but little for a long 
time. The tumor may be mistaken for cancer, a displaced spleen or 
kidney, fecal impaction, or a tumor of the omentum. A correct diagnosis 
is seldom made until operation is done. In a few instances the tumor 
has disappeared after catharsis. If operation is done the outcome is 
almost always favorable. 



CHAPTER YI 
DISEASES OF THE INTESTINES 
MALFORMATIONS AND MALPOSITIONS 

Malformations are not very frequent, but are of great variety. 
With the exception of those situated at the lower end of the intestine 
they are not of much practical importance, for the condition is such 
ordinarily as to be incompatible with life. Malformations may be met 
with at any point in the canal, but most frequently in the rectum and 
anus. Aside from these, malformations of the large intestine are much 
less common than those of the small intestine. 

Malformations of the Rectum. — In Fig. 32 are shown the usual vari- 
eties of malformation of the rectum. The most frequent is atresia of 
the anus (1). In this the cutaneous septum has not been absorbed, but 
the intestine is normal to its lower extremity. This form is readily 
curable by a surgical operation. In the next variety (2) the cutaneous 
orifice and the lower part of the rectum are normal, but a membrane 
separates this portion from the upper part of the gut; this is usually 
situated within two or three inches of the anus. The bulging of the lower 
pari of the distended intestine can usually be felt by the finger in the 
rectum, and a simple division of the membrane by a guarded bistoury 
may relieve the condition. The third form (3) is more serious. Here 
the rectum terminates in a blind pouch at a variable distance from the 
aims, and is represented below by an impervious fibrous cord. The 



MALFORMATIONS AXD MALPOSITIONS 



149 




-Malfoemations 

A, anus; R, rectum. 



of the Rectum. 



diagnosis of this condition can not positively be made without opening 
the abdominal cavity. The bulging of the intestine appreciable by the 
finger in the rectum, is the only point which differentiates the preceding 
variety from this one. Instead of atresia of the rectum there may be 
stenosis of varying degrees, which may give rise to the usual symptoms 
of stricture. This is often curable by dilatation. 

Malformations of the Small Intestine. — There may be stenosis or 
atresia at any point, often at many points. Obstruction is much more 
frequent in the upper than 
in the lower part of the 
small intestine, the most 
common seat being the duo- 
denum. Atresia is more 
often seen than stenosis. 
There may be a single point 
of obstruction, or the lumen 
of the intestine may be ob- 
literated for a considerable 
distance, the intestine being 
represented only by a fibrous 

cord which connects the two open portions, or there may be no con- 
nection between them. In all cases the intestine above is found very 
greatly distended, while that below is empty and usually atrophied. The 
causes of these multiple deformities are mainly two — fetal peritonitis 
and volvulus. In fetal peritonitis there are usually found bands of 
adhesions between the intestinal coils, and between the intestine and 
the solid viscera. Syphilis has been assigned as a cause in many cases. 
Volvulus, or a twisting of the intestine during its development, is a 
more satisfactory explanation of the majority of the cases, especially 
when there are multiple points of atresia. All these conditions are 
beyond the reach of surgical treatment. The symptoms appear soon 
after birth and are those of intestinal obstruction. The higher the point 
of obstruction the shorter the duration of life; it is rarely more than a 
week in any case of atresia; in stenosis it may be two or three months. 

Meckel's Diverticulum. — This is the remains of the omphalomesen- 
teric duct, which in fetal life forms a communication between the inn- 
tine and the umbilical vesicle. It is given off from the ileum, usually 
about a foot above the ileo-cecal valve. Most frequently it exists as a 
blind pouch from one-half to two or three inches long, communicating 
with the intestine. At the extremity of this there may be a fibrous cord, 
which is free in the abdominal cavity or attached to the umbilicus. In 
other cases the duct may remain pervious quite to the umbilicus, bo that 
there is a fecal fistula. Prolapse of the mucous membrane of the duel 

13 



350 DISEASES OE THE DIGESTIVE SYSTEM 

may lead to an umbilical tumor, described elsewhere. Meckel's diver- 
ticulum, especially when present as a cord connecting the ileum with the 
umbilicus, may compress a coil of intestine, leading to obstruction or 
even strangulation. This may occur in infancy or later in life. 

Malpositions. — The ascending colon may be found upon the left side. 
There may be a complete transposition of the abdominal viscera. In 
cases of congenital umbilical hernia a large part of the intestines may be 
found in the tumor, and in diaphragmatic hernia they may be in the 
thoracic cavity. 

DIARRHEA 

The term diarrhea is used to include all conditions attended by fre- 
quent loose evacuations of the bowels. These depend upon an increase 
in peristalsis and in the intestinal secretions. 

The importance of diarrheal diseases in children can best be appre- 
ciated by reference to the following table, showing the mortality of diar- 
rheal disease in children under two years, as compared with that from 
certain infectious diseases for all ages. 

Deaths in New York City for Five Years 

Measles, all ages 3,378 

Scarlet fever, all ages 4,152 

Pertussis, all ages 2,000 

Typhoid, all ages 3,523 

Diphtheria, all ages 10,277 

Total deaths from five diseases 23,330 

Diarrheal disease under two years 26,563 

There are several important underlying factors upon which diarrheal 
diseases depend. Their greatest frequency belongs to the first year of 
Life; and after the second year a notable diminution both in frequency 
and severity is seen, and a fatal outcome is relatively rare. The extreme 
susceptibility in infancy is due to several causes. The digestive organs 
are severely taxed to provide for the needs of the growing body. The 
mucous membrane of the gastro-enteric tract of all infants is very deli- 
cate in structure, and even in those with good health is exceedingly 
vulnerable. This vulnerability is enormously increased in the very 
young, and in those who are feeble, delicate, or suffering from any form 
of digestive disorder. The mucous membrane of the digestive tract is 
furthermore constantly exposed to injury, either mechanical or chemical, 
and to infect ion. 

Everything which lowers the general vitality increases the liability to 
diarrheal diseases. Chronic disorders of digestion, marasmus, malnutri- 
tion, and rickets are especially important factors. 



DIARRHEA 



351 



The most striking fact about diarrheal diseases is their prevalence 
during the summer season. This is graphically shown in Fig. 33, where 
are given by months the mortality records from this cause for Xew York 
City for ten years. 



F. 


C. 


Jan. 


Feb. 


Mar. 


Apr. 


May. 


June. 


July. 


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Fig. 33. — Mortality from Diarrheal Diseases in New York for Ten Years in 
Children Under Five; Compared with the Mean Temperature for the Same 
Period. , mortality; , mean temperature. (Scibert.) 

While diarrheal diseases are met with in all seasons they regularly 
increase with the advent of hot weather. In this country the higher 
summer temperature of the inland cities, Philadelphia and Chicago, is 
associated with a higher mortality from diarrheal diseases than is seen in 
Boston and Xew York with a lower range of temperature. Thus in 
Philadelphia and Chicago 32 per cent of the deaths under one year have 
been due to diarrheal diseases; while in Xew York but 27 per cent, in 
Boston but 19 per cent, and in London but 13 per cent have been from 
this cause. The large cities of northern Europe — London, Paris and 
Berlin — witness nothing like the mortality from diarrheal diseases seen 
in the large cities of the United States. 

How atmospheric heat acts in causing diarrheal diseases is uol yei 
entirely settled. It was long the prevailing opinion that it was the effect 
of heat upon the infant's food, especially the bacterial contamination of 
cow's milk, that was the chief cause of diarrhea in summer. Without 
doubt thoroughness of milk inspection and the general use of sterilized 
milk in summer have materially reduced the mortality from this cause. 
But notwithstanding all the attention given to food there remains an 
enormous summer mortality from diarrhea. Prom the most reeenl study 
of this question the conclusion seems irresistible that heal Itself has a 
direct, injurious effect upon the infant, and that it is not so much i In- 
outdoor temperature which counts as the stagnant heat of apartments in 
which the infant lives night and day. The effects of heat are intensified 
by want of ventilation and all unhygienic surroundings. Heat under 



352 DISEASES OF THE DIGESTIVE SYSTEM 

these conditions acts as a powerful depressant of the vital forces, dis- 
turbing metabolism, causing indigestion and diarrhea. 

Diarrheal diseases are especially seen in cities, for there are combined 
the conditions of poverty, neglect, bad food and bad hygiene, all of which 
are important causes. That overcrowding and bad housing in our large 
cities are not the chief factors is shown by the fact that the death rate 
from diarrheal diseases is often higher in smaller places, especially 
factory towns, than large cities. Thus in New York State it has been 
higher in Troy, Cohoes and Newburgh than in New York City; and in 
Massachusetts, higher in Fall Eiver and Lowell than in Boston. 

Artificial feeding is an etiological factor of the first importance. Less 
than 5 per cent of the severe cases of diarrhea are among the breast-fed, 
and fatal cases among the exclusively breast-fed are really rare, no matter 
how bad the surroundings or how ignorant the mothers. Breast-feeding 
requires but little experience, and may be very successfully done even by 
those with a very low grade of intelligence and among the poor; but 
artificial feeding is not successful unless done with much intelligence 
and experience and also with good milk. 

It is in factory towns, where the mothers work away from their homes 
and as a consequence breast-feeding is either not practiced at all or only 
for a short time, and where artificial feeding is usually badly done, that 
we see the highest mortality from diarrheal diseases. These conditions 
do not depend upon the size of the town and compared with them 
housing is of secondary importance. 

Next to the kind of feeding as a cause of diarrhea must be placed 
gross or involuntary neglect or want of proper care. Ignorance and 
stupidity are large elements in the failure of artificial feeding among 
the poor. The simplest rules of hygiene are either unknown or ignored. 
The importance of cleanliness, fresh air, regularity and quiet is not 
appreciated. L T nder such conditions an infant, though often strong and 
healthy at birth, soon falls into a condition of malnutrition or marasmus 
with such feeble resistance that he readily succumbs to the depressing 
influences of the first hot weather, the intestinal tract being the most 
vulnerable point. 

But all the other factors mentioned — artificial feeding, overcrowding, 
bad hygienic surroundings and neglect — exist the year round, yet diar- 
rheal discn scs arc prevalent only in summer. We must therefore consider 
the direct or indirect effects of atmospheric heat as the primary exciting 
cause <>f paramount importance, the other conditions acting as secondary 
or predisposing causes. 

The n>lc of impure milk is so important as to demand further dis- 
cussion ; that it can cause diarrhea in infants is a fact that is established 
beyond question. We June seen every one of twenty-three healthy chil- 



DIARRHEA 



353 



dren, all over two years old, occupying one dormitory cottage, attacked 
in a single day with diarrhea, which was traced to this cause. 

When the enormous bacterial contamination of milk began to be 
appreciated, it was thought that in this was to be found the real cause 
of the prevalence and fatality of diarrheal diseases in summer. This 
belief carried with it the expectation that by furnishing to every arti- 
ficially-fed infant a clean, fresh milk, or milk which had been pasteurized 
or sterilized, this great cause of infant mortality could largely be 
removed. It is true that a great reduction in infant mortality from 



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Fig. 34. — Deaths Under One Year per 1,000 of Population Under One Year, 
New York City. A comparison of summer deaths from all causes with summer 
deaths from diarrheal diseases for a period of twenty years. 



summer diarrheal diseases has been effected during the last two decades ; 
but it is also true that there has been quite as great a reduction in 
infant mortality in other seasons, and, in summer, from other causes 
than diarrheal diseases. (Fig. 34.) This leads us to quest ion whether 
the bacterial contamination of milk is the great cause of diarrheal 
diseases, and whether the lowered mortality in summer has nol been 
brought about quite as much by other conditions, such as better hygiene 
and care and a better understanding of infant-reeding, as by the ex- 
clusion of germs from milk or their destruction by heat. 

In the years 1901 to 1903 an investigation 1 was undertaken by The 

x The full report was published by Park and Holt in the Medical \< W8 t D< - 
cember 5, 1903. 



354 DISEASES OF THE DIGESTIVE SYSTEM 

Rockefeller Institute and the Health Department of New York to secure 
data regarding the following points: (1) The results in infant-feeding 
obtained with milk of different degrees of purity both in winter and in 
summer, as shown by the gain or loss in weight, the amount of gastro- 
intestinal disturbance, and the death rate; (2) the relation, if any, 
existing between the number of bacteria present in the milk and the 
frequency of diarrheal disease; (3) whether any organisms with patho- 
genic properties could be found in milk to which diarrheal disease could 
be ascribed as a cause; (4) whether the practice of heating milk — pas- 
teurization or sterilization — affected the results obtained with any given 
milk; (5) to what degree older children as well as infants were affected 
by bacterial contamination of milk. 

Observations were made upon 592 bottle-fed infants living in tene- 
ments of New York; 202 were observed in winter and 390 in summer. 
The infants were well when the observations were begun, and were 
watched for a period of about three months, being visited regularly by 
physicians. Samples of milk as fed were frequently examined as to the 
number and character of the bacteria present. Observations were pos- 
sible upon infants taking (1) condensed milk, (2) the cheapest grade of 
store milk, (3) a better grade of milk delivered in bottles, (4) the best 
bottled milk sold in the city, all of the above being prepared at home, 
(5) milk modified at milk stations and dispensed in separate feeding- 
bottles. 

During the winter, the mortality was but 2.5 per cent, and in but 
one case was death due to disease of the digestive tract. The health of the 
infants observed was not appreciably affected by the kind of milk nor 
by the number of bacteria which it contained. The different grades of 
milk varied much less in bacterial contamination in winter than in 
summer, the cheap store milk averaging only about 750,000 per c.c. 

During the summer, the mortality was 10.5 per cent, four-fifths of the 
deaths being clue to diarrheal disease. The worst results were seen in 
those whose food was either the cheap grade of store milk or condensed 
milk, and in those who received the poorest care. 

The number of bacteria which milk may contain before it becomes 
noticeably harmful to the average infant in summer is not at all uniform. 
Of the usual varieties present, no strikingly deleterious results were seen 
until the number approached the one million mark. But much above 
I his poinl injurious effects were usually manifest. Below it other factors 
seemed of greater importance in producing diarrhea. Thus in condensed 
milk the bacterial contamination was relatively small, yet the results 
were almost as bad as with the most highly contaminated milk. 

No relationship could he discovered between any special forms of 
bacteria present and (he health of children or the occurrence of diarrhea. 



DIARRHEA 



3.55 



To test the effect of heating milk, observations were made during 
two summers upon 92 infants taking milk prepared at a milk station. It 
was from a good farm, and had been kept properly cooled. The infants 
were divided into two groups as nearly alike as possible. To one group 
the milk was given pasteurized (165° F. for thirty minutes), to the other 
group the same milk was given raw. All the infants were well at the 
beginning of the period of observation. The results are shown in the 
following table: 



Food. 


Total 

Number of 

Infants. 


Remained 

Well Entire 

Summer. 


Had 

Severe 

Diarrhea. 


Average 

Days 
Diarrhea. 


Death: 


Pasteurized milk containing 1,000 
to 50,000 bacteria per c.c. at the 
time of use 


41 
51 


31 
17 


10 
34 


4 

113/2 


1 


Raw milk containing 1,200,000 to 
20,000,000 bacteria per c.c. at 
the time of use 


') 







Thirteen of the fifty-one infants on raw milk were changed before 
the end of the season to pasteurized milk because of serious diarrhea; 
but for this the results with raw milk would have been even more un- 
favorable. A similar experiment was made a third season with almost 
identical results. 

Although the number of cases is not large, the results, which were 
practically uniform for three successive seasons, show unmistakably that 
in hot weather raw milk, although from a good source, but at the time 
of feeding highly contaminated with bacteria, causes illness in a much 
larger number of cases than when it has been previously heated. 

After the first two years, children are much less affected by bacteria 
in milk. The observations seemed to show that milk from healthy cows, 
produced under cleanly conditions and kept at a temperature below 
(50° F., although containing large numbers of bacteria, sometimes 
amounting to many millions per c.c, might be taken in considerable 
quantities and for long periods by children over three years old, wit lion i 
any appreciably harmful effects. A single example is typical of a number 
of observations made. An orphan asylum, containing (>.">(> children from 
ibree to fourteen years old, used during an entire summer milk in which 
the bacteria ranged from 2,000,000 to 20,000,000 per c.c.; yel during 
this period there occurred no case of diarrhea of sufficient severity to 
call a physician. The milk was kept cold, but was given without steriliza- 
tion. Mere numbers of bacteria certainly appear to count for much less 

than was once supposed. lint the I'aet should not he overlooked that 

milk abounding in bacteria because of careless handling i> also always 



350 DISEASES OF THE DIGESTIVE SYSTEM 

liable to contain pathogenic organisms derived from human or animal 
sources. 

These observations, continued for three seasons and giving each 
summer nearly identical results, indicate that we are to seek elsewhere 
than in a moderate bacterial contamination of milk the great cause 
of summer diarrheas. Though it is clear that excessive bacterial 
contamination is highly detrimental to infants, we must certainly look 
to the other factors for the explanation of a very large, possibly the 
largest, proportion of the cases. Of the other exciting causes, atmospheric 
heat, especially the stagnant heat of houses, is clearly first in importance. 
This may act by so interfering with normal digestion and metabolism 
as to lead to the formation within the body of injurious substances which 
excite diarrhea; or it may favor the excessive growth of bacteria ordi- 
narily present in the digestive tract. In this group of cases the- role 
of the bacteria seems to be secondary, though perhaps a very important 
one. According to this hypothesis, the exciting cause of the diarrheas 
under consideration is not something introduced from without, but some- 
thing produced within the body itself. 

From the foregoing discussion the measures to be employed in the 
prevention of diarrheal diseases are inferred. In the order of importance 
they are as follows : 

1. Encouragement of maternal nursing and the adoption of measures 
to make this possible, particularly during the summer months. 

2. Education of mothers in all matters relating to the care and 
hygiene of infants, best through the agency of the milk station and the 
visits of a trained district nurse. 

3. Adequate supervision of the milk supply, the general use of pas- 
teurized or sterilized milk during the summer, and furnishing good milk 
to those too poor to pay for it. 

4. Instruction of mothers in regard to the care of milk in the home 
and in all matters of artificial feeding. 

5. The constant supervision of artificially-fed infants either in the 
milk station or by visits to the home. 

The adoption of these measures and their application on an extended 
scale by an efficient organization has resulted in a very great reduction 
in the deaths from diarrheal diseases wherever they have been tried. 
Nowhere have such results been achieved as in New York City, where 
the summer mortality in infants under one year has fallen in the 
Boroughs of Manhattan and Bronx from an average of 106*9 for the 
three years L908-10 to an average of 802 for the three years 1912-1 1. 
(Sec Fig. 5, Chapter on Infant Mortality.) These figures represent the 
actual Dumber of deaths and take no account of the increase in popula- 
tion. 



ACUTE INTESTINAL INDIGESTION AND DIARRHEA 357 

Another group of diarrheal diseases is seen which may be due to in- 
fection introduced from without, through water, milk, or other food; 
to these the term dysentery is more often applied. These cases have 
been found to be associated with definite bacteria or amebae. It is likely 
that intestinal disease of this type may supervene upon other forms. 



ACUTE INTESTINAL INDIGESTION AND DIARRHEA 

The term intestinal indigestion is not an accurately descriptive one 
but is as satisfactory as any that has been proposed until more exact 
knowledge as to the etiology and pathology of the condition is available. 

The cases included in this chapter comprise many types which, how- 
ever, are closely allied and shade into one another. Though the extremes 
of the series differ as widely as possible, yet intermediate types of almost 
every grade are met with. They are discussed under a single heading, 
since they have no essential anatomical differences, nor, so far as yet 
determined, do they differ etiologically. Some of the attacks are so 
mild in character that in children with normal resistance, and receiving 
prompt treatment, they may last but a few hours. On the other hand, 
they may be so rapid in development and so severe as to result in death 
in a few hours ; or, beginning with less intensity, they may be the start- 
ing point of prolonged functional disorders or may prepare the way for 
the development of infectious processes. 

Etiology. — The most important causes have been mentioned in the 
foregoing discussion on the General Etiology of Diarrheal Diseases. A 
predisposition to attacks is furnished by summer weather, a delicate con- 
stitution, and any previous derangement of digestion. The exciting cause 
of an attack may be the use of improper food, overfeeding or some sudden 
change in food as in weaning; but, the food remaining unchanged, it is 
often other influences affecting the child, such as summer heat. The 
most striking thing about these cases is their prevalence during hot 
weather. Year after year for generations have been repeated in New 
York the conditions which are graphically represented in Fig. .'>:>, viz., 
an epidemic which, beginning in June, rapidly increases in severity, 
reaching its height in July or August, from which time it diminishes 
steadily, regularly coming to an end in September. 

Despite the fact that since 188G many series of bacteriological studies 
of the intestinal discharges have been made by Booker and by Park in 
this country, by Escherich, Baginsky, and others in Germany, our knowl- 
edge of this subject is still very incomplete. So far as is now known, 
no one form of bacteria can be assigned as the cause of 1 1) is group of 
diarrheas. There seems to be evidence that the Shiga bapilhis may 



358 DISEASES OF THE DIGESTIVE SYSTEM 

produce diarrheal disease which clinically does not differ from this type. 
But it is wanting in so large a proportion of cases, that it can not be 
regarded as the specific cause. With existing knowledge it seems probable 
that there are a number of organisms present in the intestine in disorders 
of digestion, which, under favorable conditions, may multiply to such a 
degree as to produce serious disturbances; but the role of the micro- 
organisms may be regarded as a secondary one. 

There are certain cases in which symptoms of a severe type develop 
abruptly in children previously quite well. These only are to be regarded 
as examples of acute milk poisoning. Although the bacteria in the milk 
may have been previously destroyed by sterilization, the toxins produced 
by them may still be present. This is doubtless the explanation of the 
simultaneous development of several cases in families or institutions. 

We can not believe that direct contagion is the usual way in which 
this disease is spread. When occurring in institutions or in families, it 
usually happens that a number of children are attacked simultaneously 
rather than successively, this indicating a common cause, usually to be 
found in the food, the surroundings, or the atmospheric conditions. 

The irritating substances producing the diarrhea are largely the lower 
fatty acids. These are derived from the sugar and fat of the food prob- 
ably as the result of bacterial action. It is not the presence of abnormal 
bacteria that brings about this result so much as the altered conditions 
under which they multiply and operate. These altered conditions may 
depend upon changes in the gastric, biliary, pancreatic and intestinal 
secretions or upon other factors that we do not yet understand. 

Lesions. — In the milder cases which end in recovery, the anatomical 
changes are probably negligible. In those which prove fatal from the 
disease itself, or from some associated condition, the lesions may be 
a superficial catarrhal inflammation affecting the entire gastro-enterie 
tract, but varying much in severity in the different regions and in the 
different cases. Even after the most severe symptoms no lesions of con- 
sequence may be found. 

The gross appearances may show but little that is abnormal. The 
walls of the stomach may be coated with mucus, and the mucous mem- 
lu -a ue may show congestion, generally in patches. The mucous membrane 
of the small intestine may be pale throughout; there are often irregular 
areas of congestion. With this there may be redness and swelling of 
IVver's patches and the solitary follicles. In the colon the mucous mem- 
brane may be congested. The solitary follicles are usually swollen. The 
changes described are not at all uniform, and do not differ very greatly 
from the appearances often seen in the intestines when patients have 
died of oilier diseases. 

In the cases classed clinically as cholera infantum, the pathological 



ACUTE INTESTINAL INDIGESTION AND DIARRHEA 359 

changes are sometimes more characteristic. The greater part of the small 
intestine, and sometimes the entire colon, are distended with gas, and 
contain material of a grayish- white color about the consistency of a thin 
gruel. It has a mawkish odor, but usually not a very offensive one. The 
mucous membrane of the entire intestinal tract is in most cases pale. 
Sometimes this is only in the small intestine, while there are areas of 
congestion in the colon. If cholera infantum has been engrafted upon 
some other pathological process in the intestines, as is not infrequent, 
there is found post-mortem evidence of this in the form of severe 
catarrhal inflammation, sometimes old ulcerations. 

Unless autopsies are made very soon after death — at most within 
four hours — it is not safe to draw conclusions from the conditions found, 
as post-mortem changes take place rapidly, and resemble those of the 
disease under consideration. This applies particularly to the micro- 
scopical examination of the epithelium. The cells may still be present, 
but with the cell protoplasm and nuclei so changed that they do not stain 
normally. In more severe and prolonged cases the superficial epithelium 
in places is entirely destroyed. 

The changes in and about the blood-vessels are variable. The small 
vessels may be distended, and there may be hemorrhages or an exuda- 
tion of leucocytes in their neighborhood. These appearances are seen 
either in the mucous or submucous layer. Peyer's patches and the lymph 
nodules may be enlarged from cell-proliferation. 

The lesions in other organs are less frequent and less severe than 
in the more protracted cases of ileocolitis. Acute bronchitis and broncho- 
pneumonia are frequent. Acute degeneration of the kidney is found to 
some degree in every case which is severe enough to cause death, and in 
a few there is acute nephritis. The liver may be much enlarged and 
very fatty or of normal size, but degeneration of the liver cells is fre- 
quent. • There may even be small areas of necrosis. In rare eases a 
general septicemia, due most frequently to the streptococcus, is pres- 
ent. 

Symptoms. — Clinically, these cases may be divided into four groups: 
(1) The mild form, with definite local symptoms, but few general ones; 
they may be of short duration or protracted; (2) the severe form in 
which there are not only local but marked constitutional symptoms, 
fever, etc.; (•'>) cholera infantum; (-1) severe forms complicated by 
acidosis. 

The Mil'/ Form. — In infants, the symptoms are seldom limited either 
to the stomach or to the intestine, although in one case the disturbance 
of the stomach is slight and that of the intestine serious, and in another 
the reverse may be observed. In these little patients the intestinal Bymp- 
toms are more frequent, and, as a rule, more severe than those referable 



360 DISEASES OF THE DIGESTIVE SYSTEM 

to the stomach. In older children it is not uncommon to see the in- 
testinal symptoms alone. In infants, if the attack develops suddenly, 
gastric symptoms are usually present ; if more gradually, they are usually 
absent. The local symptoms are colicky pain, tympanites, and later 
diarrhea. The constitutional symptoms, prostration and nervous dis- 
turbances, are slight or absent. Pain is indicated by the sharp, piercing 
cry, great restlessness, and drawing up of the legs. Tympanites is rarely 
very marked. The stools are always increased in number and are from 
four to twelve a day. If more frequent they are very small. The first 
stools are more or less fecal, but this character is soon lost. The color 
is at first yellow, then yellowish-green, and finally often grass-green. 
This color is due to biliverdin. If the child has been taking milk, masses 
of undigested milk, chiefly fat, are present. The reaction of the stools 
is almost invariably acid. The odor may be sour, or it may be foul. 
The stools are much thinner than normal, and often frothy from the 
presence of gases. Blood is not present, nor is much mucus seen, unless 
the symptoms have lasted several days. The microscope shows, in addi- 
tion to food-remains, epithelial cells, usually of the cylindrical variety, 
which are numerous in proportion to the severity and duration of the 
attack. The bacteria are the ordinary forms found in the feces. 

The course and termination of the disease depend upon the previous 
condition of the patient, the nature of the exciting cause, and the treat- 
ment employed. In a previously healthy child, if the cause is at once 
removed and proper treatment instituted, the severe symptoms rarely 
last more than a day or two, and in four or five days the patient may be 
quite well. In delicate infants, a severe attack of acute intestinal in- 
digestion in the hot season is likely to prove the first stage of a patholog- 
ical process which may continue until serious organic changes in the 
intestine have taken place. This result may not follow the first attack, 
but one is often succeeded by others until it occurs. If circumstances 
are such that proper dietetic treatment and general hygienic measures 
can not be carried out, this termination is very common. 

In older children most of the cases seen are of the milder type. The 
onset is often with vomiting; pain is generally mild and precedes diar- 
rhea by several hours. It is seldom localized but is more often referred 
to the navel. The stools are loose, frequent, and contain undigested 
food, and are of almost every conceivable color and variety. The tem- 
perature, if elevated at all, is so only for a short time. There is anorexia 
and a coated tongue. With proper treatment the attack is usually over 
in ;i few days. It is very seldom followed by the severer types of diarrhea, 
jis is so commonly I he case 1 with infants. 

The Severe Form. — This may follow after several days of an ap- 
parently mild attack, especially during hot weather or if improperly 



ACUTE INTESTINAL INDIGESTION AND DIARRHEA 361 

treated. In the cases developing suddenly, the clinical picture is quite a 
definite one. 

An infant is restless, cries much, sleeps but a few minute^at a time, 
and seems in distress. The skin is hot and dry, the temperature rises 
rapidly to 102° or 103° F., sometimes to 106° F., and all the symptoms 
indicate the onset of some serious illness. He may lie in a dull stupor, 
with eyes sunken, weak pulse, and general relaxation, or there may be 
restlessness, excitement, and even convulsions. There may be great 
thirst, so that everything offered is eagerly taken, or everything may be 
refused. Vomiting may be an early and important symptom. It is first 
of food, often that which was taken many hours before; retching con- 
tinues even after the stomach has been emptied, so that mucus, serum, 
and sometimes bile may be ejected. Vomiting does not usually persist 
throughout the attack, and in many cases it is absent altogether. Diar- 
rhea is sometimes delayed for several hours after the beginning of the 
grave constitutional symptoms. At first there are fecal stools, then great 
bursts of flatus, with the expulsion of a thin yellow material with an offen- 
sive odor. Four or five such discharges may occur in as many hours. At 
other times the stools are gray, green, or. greenish-yellow, and sometimes 
brown. The characteristic features are the amount of gas expelled, the 
colicky pains preceding the discharges, and the foul odor. After the 
first day the stools may be almost entirely fluid, varying in number from 
six to twenty a day, and often large even then ; but their offensive charac- 
ter frequently disappears. After two or three days mucus appears. The 
microscopical examination of the stools shows great numbers of separate 
epithelial cells, and sometimes groups of cells attached to a basement 
membrane. In addition there may be leucocytes and some red blood- 
corpuscles. 

In many cases the free evacuation of the bowels is followed by a drop 
in the temperature and subsidence of the nervous symptoms, and the 
child may fall asleep. The prostration, though often great in the be- 
ginning, may not be of long duration. In the most favorable cir- 
cumstances, after one or two days of severe symptoms, convalescence may 
take place. The stools continue frequent for five or six days, but grad- 
ually assume their normal character, and recovery follows. The chief 
factors contributing to such favorable results are a good constitution 
on the part of the child, prompt and intelligent treatmeni at the outset, 
and proper feeding afterward. 

If the circumstances are not so favorable, if the patienl is ;i very 
young or delicate infant, there may be no reaction from the firsj severe 
symptoms, and the attack may terminate fatally in from one !<> three 
days. Tn such cases the temperature remains high; the stomach may 
or may not be disturbed; but the diarrhea, prostration, and nervous 



3G2 



DISEASES OF THE INTESTINES 



symptoms continue, and death occurs from exhaustion, in coma or con- 
vulsions. Instead of a rapidly fatal termination, the severity of the 
early acute symptoms may abate somewhat, and the attack assume the 
character of ileocolitis, with a lower but continuous temperature of 100° 
to 102° F., frequent mucous stools, wasting, etc. The urine is scanty 
and concentrated, and in most of the severe cases with very high tem- 
perature contains a small amount of albumin, and occasionally a few 

hyaline and granular 
casts. These are the 
result of degenerative 



100 



n 



I 



1 



changes in the renal 
epithelium. In rare 
cases there are evi- 
dences of acute ne- 
phritis. Bronchopneu- 
monia is sometimes 
seen. 

It not infrequently 
happens, after the 
storm of the acute at- 
tack with its high 
temperature, intense 
prostration, and grave 
nervous symptoms is 
passed, and the stools 
are so much improved 
that the patient is re- 
garded as out of dan- 
ger, that all the 
former symptoms may develop with such rapidity and severity as some- 
times to carry off the patient in from twelve to twenty-four hours. Such 
relapses are generally excited by some mistake in the diet, usually that 
of allowing milk too soon. The amount of milk given may be small, and 
vol the symptoms follow its administration so soon that there can be 
little doubt regarding the connection between them (Fig. 35). Besides 
such severe cases, many milder relapses are seen; the cause is usually 
some error in diet. 

Al hicks of acute intestinal indigestion with severe constitutional 
symptoms in which there is at first no diarrhea, but constipation instead, 
are most puzzling and frequently serious. Fortunately, they are not of 
common occurrence. It is somewhat difficult to explain such cases. 
There seems lo exisl for the lime almost complete intestinal paralysis. 
The toxic materials are locked up in the small intestine, for the colon 



Fig. 35. — Severe Intestinal Indigestion with Fatal 
Relapse. Infant five months old; early symptoms, 
both intestinal and nervous, severe; rapid improve- 
ment followed stopping milk, free catharsis and irriga- 
tion. After stools had been nearly normal for three 
days relapse occurred, apparently from adding milk to 
the diet, although less than two ounces a day were 
given. Autopsy: Only mild intestinal lesions were 
present; other organs essentially normal. 



A€UTE INTESTINAL INDIGESTION AND DIARRHEA 363 

is frequently quite empty. When one meets such a ease he can appreciate 
the fact that diarrhea is a conservative process of the greatest possible 
value. 

In children over two years old there are seen some features which 
differ from those of the cases above described as occurring in infants. 
The attacks are more often due to other causes than to milk. Vomiting 
does not occur so readily as in infants, pain is a more prominent symp- 
tom, and the temperature, as a rule, is lower. The nervous symptoms 
are much less prominent. Skin eruptions, however, are more frequently 
seen, particularly urticaria, which is a feature of many attacks, and in 
obscure cases has some diagnostic value. Although often beginning with 
severe symptoms, these cases usually make good recoveries; there is much 
less danger of repeated attacks or of the development of ileocolitis than 
in the case of infants. 

Cholera Infantum. — This is only one type of the severe form of acute 
indigestion, yet clinically it differs from the others sufficiently to deserve 
separate consideration. It is not, however, a frequent form. What it is 
that determines the marked and characteristic symptoms in cholera 
infantum is entirely unknown. 

Cholera infantum rarely occurs in an infant previously healthy. As 
a rule, there is some antecedent intestinal disorder. The development 
of the choleriform symptoms is usually very rapid, and a child, who 
perhaps has been regarded as scarcely ill enough to require a physician, 
may be brought, in the course of five or six hours, to death's door. 

Usually there are general symptoms, such as prostration and a stead- 
ily rising temperature, for a few hours before the vomiting and purging, 
or these symptoms may be the first to excite alarm. Vomiting may pre- 
cede diarrhea, or both may begin simultaneously. The vomiting is very 
frequent. First, whatever food is in the stomach is vomited, then serum 
and mucus, and sometimes there is regurgitation from the small intes- 
tine. If vomiting subsides for a time, it is almost sure to begin anew 
with the taking of food or drink. The stools are frequent, large, and 
fluid, and may occur once or twice an hour. They arc of a pale green, 
yellow, or brownish color in the beginning, but as they become more 
frequent they often lose all color and are almost entirely serous. The 
sphincter is sometimes so relaxed that small evacuations occur every 
few minutes. The first stools are usually acid, later they are neutral, 
and when serous they are alkaline. In most cases tiny an> odorless; 
in rare instances they are exceedingly offensive. Microscopically tin- 
stools show large numbers of epithelial cells, some leucocytes, and im- 
mense numbers of bacteria. 

Loss of weight is more rapid than in any other pathological condition 
in childhood; it may be as much as a pound a day. The fontanel is 



364 DISEASES OF THE DIGESTIVE SYSTEM 

depressed, and in rare instances there may be overlapping of the cranial 
bones. The general prostration is great almost from the outset. The 
face, better, perhaps, than any single symptom, indicates what a pro- 
found impression has been made upon the system. The eyes are sunken, 
the features sharpened, the angles of the mouth drawn down, and a 
peculiar pallor with an expression of anxiety overspreads the whole 
countenance, which becomes almost Hippocratic. In the early stages 
the nervous symptoms are those of irritation. Later, these symptoms 
give place to dulness, stupor, relaxation, and coma or convulsions. 

The temperature is invariably elevated, and usually in proportion to 
the severity of the attack. In cases recovering, it has generally been 
from 102° to 103° F., while in fatal cases it has risen almost at once 
to 10-1° or 105° F., and often shortly before death it has reached 
106° or even 108° F. Such temperatures may occur with a clammy skin 
and cold extremities, and are discovered only with the aid of a ther- 
mometer. The pulse is always rapid, and very soon it becomes weak, 
often irregular, and finally almost imperceptible. The respiration is 
irregular and frequent, and may be stertorous. The tongue is generally 
coated, but soon becomes dry and red, and is often protruded. The 
abdomen is generally soft and sunken. There is almost insatiable thirst. 
Everything in the shape of fluids, especially water, is drunk with avid- 
ity, even though vomited as soon as it is swallowed. Very little urine 
is passed, sometimes none at all for twenty-four hours; this largely 
depends upon the great loss of fluid by the bowels. 

In the fatal cases there is hyperpyrexia, a cold, clammy skin, absence 
of radial pulse, stupor, coma or convulsions, and death. The diarrhea 
and vomiting may continue until the end, or both may entirely cease for 
some hours before death occurs. The patients may pass into a condition 
resembling the algid stage of epidemic cholera, and die in collapse. In 
other cases, after the first day of very severe symptoms, the discharges 
diminish, but the nervous symptoms become specially prominent. There 
is restlessness and irritability or apathy and stupor. The fontanel is 
sunken; the eyes are half open and covered with a mucous film; respira- 
tion is irregular and superficial, sometimes even Cheyne-Stokes ; the 
pulse is feeble, irregular, or intermittent; the muscles of the neck drawn 
back; the abdomen retracted. The temperature is not elevated, but 
normal or subnormal. From this condition recovery may take place or 
the symptoms may merge into those of ileocolitis; but much more fre- 
quent than either of the foregoing is the fatal termination. 

The nervous symptoms have been ascribed to cerebral anemia, cerebral 
hyperemia (venous), edema of the meninges, thrombosis of the cerebral 
sinuses, and uremia. Although we have examined the brain in almost 
all our autopsies upon patients dying from diarrheal diseases, we have 



ACUTE INTESTINAL IX DIGESTION AND DIARKHEA 3G.1 

never in such cases seen sinus thrombosis, and but rarely edema. Cere- 
bral hyperemia is often met with in eases dying in convulsions, but not 
with any regularity otherwise. Xor have our observations upon the kid- 
neys confirmed those of Kjellberg, whom most of the writers since 
his day have quoted, as to the great frequency of nephritis. A scanty, 
concentrated, and hence irritating urine is the rule, and a small amount 
of albumin and an occasi-onal hyaline cast not uncommon; but either 
clinical or pathological evidence of a serious amount of nephritis has 
been, in our own experience, extremely rare. 

An infrequent complication of cholera infantum is sclerema. This 
condition is found associated with muscular contractions, subnormal tem- 
perature and other signs of the most extreme depression. These cases are 
almost invariably fatal. 

Of the children with true cholera infantum which have come under 
our notice, fully three-quarters have died. 

Acidosis. — In the course of the severe form of diarrhea or of cholera 
infantum, symptoms referable to the nervous system and respiration may 
appear. There may be excitement and sleeplessness with a frequent, 
shrill, piercing cry. Later on there may be somnolence gradually increas- 
ing to stupor or even coma. The type of respiration is the most charac- 
teristic evidence of acidosis. This is altered so that there is an increased 
ventilation of the lungs, i. e., exaggerated inspiration and expiration. 
This is often difficult to recognize in its early stages, but frequently 
develops into a marked dyspnea of the "air hunger" type, without pause 
or cyanosis and without any evidence of obstruction. There is often a 
polymorphonuclear leucocytosis, generally between 20,000 and 30,000! 
There may be sugar in the urine which, if lactose is given in the food, 
is said to be galactose and lactose, or saccharose if this sugar is being 
taken. There are in addition the symptoms of severe general prostration. 

When such symptoms are present, especially the nervous and respira- 
tory ones, the condition is very grave. The majority of the children 
with manifest hyperpnea die, although life may be prolonged for Beveral 
days. Though the hyperpnea may cease as the result of treatment, death 
usually occurs: for many abnormal processes at present not understood 
have undoubtedly been initiated and arc sufficient to cause death. 

It is to the train of symptoms just described that the name "food 
intoxication" (alimentare intoxication) bas been given by Finklestein. 
He claims that this condition is the result of the presence of products 
of intermediary metabolism, imperfectly elaborated, and that they are 
directly poisonous. Evidence of their presence is, however, lacking. 

Recent studies have shown that in these cases there is an acidosis, 
that the disturbances of respiration are referable to this condition, and 
that the gravitv of the symptoms is probably depended directly upon 






366 DISEASES OF THE DIGESTIVE SYSTEM 

this acidosis. It has been shown that accompanying the hyperpnea there 
is a low carbon dioxid tension in the alveolar air; that the greater the 
liyperpnea, the lower the carbon dioxid tension; that in the most severe 
forms there is an increase in the hydrogen-ion concentration of the blood 
serum ; that there is a great diminution of the alkali reserve of the blood 
and that a greatly increased quantity of alkali can be taken before the 
urine becomes alkaline. Soda bicarbonate, given by mouth, intravenously 
or subcutaneously, causes a cessation of the hyperpnea and a return of the 
alkalinity of the blood to normal. This furnishes a definite indication 
for treatment. But the relief of the acidosis does not necessarily cure 
the diarrhea. There is no doubt that there is an alteration in the 
normal relation between the acids and alkalies so that the former are 
in relative excess. What causes this alteration is not known at the present 
time. It is not due, as a rule, to an excess of the acetone bodies. These 
are but moderately increased in amount. 

Diagnosis. — The acute gastric and intestinal symptoms which mark 
the beginning of many febrile diseases in infancy, particularly the exan- 
themata and pneumonia, are often difficult to distinguish from the more 
severe attacks of acute indigestion with constitutional symptoms. The 
question to decide is whether the digestive symptoms are the cause or the 
result of the fever. It is sometimes not until the case has been watched 
for some time that one can be certain. Usually when digestive symptoms 
are secondary they diminish after the first day or two, although the 
severity of the general symptoms may steadily increase. The character- 
istic features of the primary disease may also appear. When the nervous 
symptoms of the severe form of acute indigestion are prominent at the 
outset, it is sometimes difficult to exclude meningitis. We have seen 
many cases where great doubt existed for several days. One should 
always hesitate to make a diagnosis of meningitis when marked diarrhea 
is present. 

Prognosis. — The milder forms of acute intestinal indigestion do not 
often prove fatal, except in young infants or those already suffering from 
malnutrition. In all cases the prognosis depends upon the previous 
health of the child, his surroundings, the season of the year, and whether 
or not the case receives prompt and proper treatment. Severe forms of 
flic disease, especially those associated with nervous or respiratory symp- 
toms, are very serious. A continuously high fever is a bad prognostic 
sign. The existence of rickets, pertussis, or any other disease, greatly 
increases the gravity of the attack. True cholera infantum is nearly 
always fatal. 

Prophylaxis. — A better understanding of the etiology brings with it 
great possibilities in the prevention of this disease. 

Prophylaxis must have regard, first, to the hygienic surroundings of 



ACUTE INTESTINAL INDIGESTION AND DIARRHEA 367 

children, and to all sanitary conditions of cities. City children should 
be sent to the country, whenever it is possible, for the months of July 
and August. Where a long stay is impossible, day excursions do much 
good. The fresh-air fluids and seaside homes have done much in New 
York to diminish the mortality from diarrheal diseases. 

The second part of prophylaxis relates to food and feeding. Mater- 
nal nursing should be encouraged by every possible means. Nothing is 
better established than the close relation existing between artificial feed- 
ing and diarrheal diseases. Yet, as stated elsewhere, it is not artificial 
feeding per se but ignorant and improper feeding. Among infants in 
private practice who are properly fed these attacks are not common. 

Overfeeding is particularly to be avoided during days of excessive 
heat. It is at such times an excellent rule with infants to diminish each 
feeding by at least one-half, making up the deficiency with water, and to 
give water very freely between the feedings. In summer all water given 
to infants or young children should be boiled. Children, like adults, 
require less food in very hot weather, but more water. Infants cry more 
from thirst and heat than from hunger, and even those at the In-east are 
likely to be given too much food. Infants should never be fed more fre- 
quently, but always less frequently, during hot weather. 

A very important work in practical philanthropy among the poor of 
our large cities in summer is to provide means for supplying pure milk 
to infants. This has been done on a large scale in many American 
cities, and it is one of the important agencies that have effected a decided 
reduction in the death-rate from diarrheal disease. Tt is not enough to 
furnish to the poor a pure, clean milk in bulk, or even in sealed quart 
bottles. The advantages of such milk may be entirely lost by the way 
in which it is cared for in the home or the way in which it is U>(] to 
infants. Since the milk must usually be kept at home without ice, steril- 
ization is advisable. When milk is distributed from milk stations, a 
physician should be in charge who can keep a general supervision over 
the children, and advise as to the quantity of food. Dumber of feedings, 
and the formula to be used. His work should he supplemented by visits 
of nurses to the homes of patients. An essential feature is to keep such 
close supervision over the infants as to recognize at once and promptly 
treat slight disturbances of digestion. 

But even more important than pure milk is the education of the 
poor in all matters relating to infant feeding mid hygiene. In no way 
can this educational work heifer he done than in connection with milk 
distribution. 

Hygienic Treatment. — If the attack i> a Bevere one and occurs in t\\' 
excessive heat of midsummer, and does not readily yield to treatment, 
the child should, if possible, be senl to a cooler place. Convalescent cases 



368 DISEASES OF THE DIGESTIVE SYSTEM 

should also be sent away on account of the dangers of relapse. Children 
must not only be sent away, they must be kept away until quite recov- 
ered. In cases which have become somewhat chronic, more can some- 
times be accomplished by a change of air than by all other means. 

Fresh air is of the utmost importance for all diarrheal cases in sum- 
mer. No matter how much fever or prostration there may be, these 
children do better if kept out of doors the greater part of the day. 
Children should be kept quiet, and especially should not be allowed to 
walk, even if they are old enough and strong enough to do so. 

The clothing should be very light flannel; a single loose garment is 
preferable. Linen or cotton may be put next the skin if this is very 
sensitive and there is much perspiration. At the seashore and in the 
mountains, care should be taken that sufficient clothing at night is sup- 
plied. Bathing is useful to allay restlessness, as well as for the reduction 
of temperature. Scrupulous cleanliness should be secured in the child's 
person and clothing. Napkins, as soon as soiled, should be removed from 
the child and from the room and placed in a disinfectant solution. Ex- 
coriations of the buttocks and genitals are to be prevented by absolute 
cleanliness and the free use of some absorbent powder, such as starch and 
boric acid. 

Dietetic Treatment. — It is of the first importance to remember that 
during the early stage of the acute cases, digestion is practically arrested. 
To give food at this time, manifestly can do only harm. 

In nursing infants the severe forms of the disease are extremely 
rare ; but the breast should be withheld so long as a disposition to vomit 
continues, and no food whatever given for at least twenty-four hours. 
Thirst may be allayed by giving frequently, but in small quantities, 
boiled water or thin barley or rice water or weak tea sweetened with 
saccharin. If these are refused or vomited, absolute rest to the stomach 
will do more than anything else to hasten recovery. After the stomach 
has been allowed to rest for twenty-four hours, it is generally safe to 
permit a nursing child to take the breast tentatively. The intervals of 
nursing should not be shorter than four hours, and the amount allowed 
at one feeding should not be more than one-fourth the usual quantity. 
This may be regulated by allowing an infant to nurse at first only two or 
three minutes. Between the nursings may be given boiled water or 
barley water. Nursing may be gradually increased, so that in three or 
four days the breast may be taken exclusively. 

In infants who are being artificially fed, all food, and especially 
milk, should be stopped at once. Sweet milk should not only be with- 
held during the period of acute symptoms, but for several days there- 
after. Besides the articles mentioned above as suitable for the period 
of most acute symptoms the following substitutes for milk will be found 



ACUTE INTESTINAL INDIGESTION AND DIARRHEA 369 

useful : rice or barley water, the farinaceous foods, and broth or bouillon 
made of Teal, chicken, mutton, or beef. Water may be allowed freely 
at all times unless there is much vomiting. 

When milk is begun it should be remembered that the sugar is more 
likely to disturb digestion than any other element and that sugar and 
fat together are very badly borne. For this reason some form of fer- 
mented milk, buttermilk or protein milk is to be preferred. This latter 
may be given except in the most severe forms of the disease and except 
when vomiting is marked, almost from the beginning of symptoms. After 
twenty-four hours of preliminary starvation, if the symptoms are very 
acute and after cleansing of the intestinal tract has taken place either 
from the diarrhea itself or from cathartics or irrigations, its use may be 
begun. It has a marked effect in counteracting the diarrhea and is 
well borne by almost all infants except those under two or three months 
of age. At first the protein milk should be given in small amounts, one 
or two ounces every four hours, and to infants under six months of age 
diluted with an equal quantity of water. The increase in amount and 
in strength should be gradually made according to the improvement in 
symptoms. No sugar should be added until a day or two after the stools 
have become quite firm in consistency and not more numerous than 
chree or four a clay. 

The sugar should be one of the dry preparations containing maltose 
such as dextrimaltose, Sohxlet's nalirzucker, Liebig's nahrmaltose or 
cane sugar. Lactose should not be used. The sugar should be added 
very gradually, beginning with one-quarter ounce a day and increased 
up to four or five per cent of the food. If loose stools result the sugar 
should be discontinued. A return to sweet milk should be made gradu- 
ally and with caution. To this no sugar should be added until it has 
been demonstrated that the diluted milk can be tolerated. Wet-nurses 
are not to be employed during the acute symptoms, but during the period 
of prolonged malnutrition which follows an acute attack they may be 
of the greatest service. 

The same general principles of feeding should be applied in older 
children. All food is to be withheld until the vomiting ceases, when 
broths and thin gruels may be given; later, buttermilk, kumysa and pro- 
tein milk. Junket from which the whey has been carefully strained is 
very useful in checking diarrhea. Solid food should not he allowed for 
several days after the stools have become normal. 

Medicinal and Mechanical Treatment. — Tt must he borne in mind 
that we are not treating an inflammation of the stomach or Intestines, 
although such may be the ultimate result of the process. The essential 
condition, it should be remembered, is one of indigestion and intoxica- 
tion arising from the intestinal contents— -food-remains from arrested 



370 DISEASES OF THE DIGESTIVE SYSTEM 

digestion, altered secretions, acids, irritating and toxic substances pro- 
duced by chemical and bacterial action — to which not only the constitu- 
tional but the local symptoms are chiefly due. We can hardly do better 
than to imitate and assist Nature in her treatment of this condition. 
Let us consider what this is. Lest too much food be swallowed, appetite 
is taken away; by vomiting, the stomach is emptied; to neutralize the 
acid poisons in the intestine, an alkaline serum is poured out from the 
intestinal walls; to remove irritant poisons, increased peristalsis is ex- 
cited. 

The first indication is, therefore, to evacuate the stomach and the 
entire intestinal tract at the earliest moment. Unless thorough evacua- 
tion of the bowels has taken place, treatment should not be begun with 
the use of measures to stop the discharges. To empty the stomach is 
not necessary in every case, since the initial vomiting may have done 
this effectively. If vomiting persists one may resort to stomach-washing. 
A single washing is generally sufficient, and if employed at the outset 
may shorten the attack. With high fever and great thirst, it is often 
advisable to leave a few ounces of water with ten to fifteen grains of 
bicarbonate of soda in the stomach. As a substitute for stomach-washing 
in children over two years old, or where it can not be employed, copious 
draughts of boiled water may be given. This is taken readily, and as it 
is usually vomited almost at once it may cleanse the stomach thoroughly. 
If there is distention with fever and foul stools, cathartics are indicated, 
but if the diarrhea has been profuse cathartics should not be employed. 
There is no greater mistake than to think that the character of the stools 
is likely to be improved by calomel or castor oil. The stools contain little 
if any fecal matter ; what is passed by the bowel consists almost entirely of 
intestinal secretions. 

To clear out the small intestine, only cathartics are available. For 
the colon, we may in addition employ irrigation. Calomel, castor oil, or 
the salines may be used as cathartics, and enough of any one of them 
must be given to clear out the intestinal tract thoroughly. Calomel has 
the advantage of ease of administration : one-fourth of a grain should 
be given every fifteen or twenty minutes up to four or six doses. When 
the stomach is not disturbed, castor oil is to be preferred as it is not so 
irritating, causes little griping and is very certain. Two drams should 
be given to a child six months old, and half an ounce to one of four years. 
Of the salines, the best arc the sulphate of soda and Rochelle salts; from 
oik! to three drams may be given, well diluted, divided into four or five 
doses, at twenty-minute intervals. 

Cathartics may be employed later in the disease if the stools become 
Foul or Www is distention, but care should be taken not to continue to 
irritate a hypersensitive intestine. 



ACUTE INTESTINAL INDIGESTION AND DIARRHEA 371 

Early irrigation of the colon is advisable in all cases, as it hastens the 
effect of the cathartic and removes at once much irritating and offensive 
material. It should be done two or three times the first day. but after- 
ward once daily is generally sufficient. A saline solution (one table- 
spoonful of salt to two quarts of water), at a temperature of about 1()(J° 
F., is to be preferred ;' and a rectal tube well inserted should always 
be used. Thorough initial evacuation, no food, but plenty of water for 
twenty-four hours, and careful feeding after that time, are all the treat- 
ment that is necessary in most cases. 

Other drugs are of secondary importance. Their value is certainly 
very much overestimated. It is very doubtful whether as yet any proper 
antiseptic treatment of the gastro-enteric tract is possible. 

Of the drugs which are used to influence the intestinal process, bis- 
muth is to be preferred. It has the advantage that it rarely causes vomit- 
ing, and that most of its preparations can be given in large doses. The 
subcarbonate is the safest. It may be given in doses of from ten to twenty 
grains every two hours, to a child of one year. Like the subnitrate it is 
insoluble and is best given suspended in the food or in water. It usually 
blackens the stools. It may be kept up throughout the attack. Our 
experience leads us to place little reliance upon astringents. They do 
little good, and often much harm. 

While opium in some form is required in many cases, it is capable 
of doing much harm. The chief indications for opium are great fre- 
quency of movements and severe pain. It is contraindicated until the 
intestinal tract has been thoroughly emptied; also when the number of 
discharges is small, particularly if they are very offensive; it is especially 
to be avoided in the early stage of very acute cases, and never to be given 
when cerebral symptoms and high temperature coexist with scanty 
discharges. Opium is admissible after the tract has been thoroughly 
emptied. It is particularly indicated when there is a persistence of large, 
fluid movements attended by symptoms of collapse, and in all eases ap- 
proaching the cholera-infantum type. Nothing requires nicer discrim- 
ination than the use of opium in diarrhea. It is wise to administer it 
always in a separate prescription, and never in composite diarrheal 
mixtures. The dose should be regulated according to its effect upon 
the number of stools. Enough is to be given to produce a distinct effect 
— the control of excessive peristalsis and the diminution of pain — bill 
never enough to check the discharges entirely, or to cause stupor. The 
uncertainty of absorption must also be remembered; a second full dose 
should not be given until a sufficient time has elapsed for the effeel of 
the first to pass away. For an average child of six months, ten minims 
of paregoric, one-half minim of the deodorized tincture, or one-half grain 
of Dover's powder, may be used as an initial dose, to be repeated every 



372 DISEASES OF THE DIGESTIVE SYSTEM 

one, two, or four hours, according to the effect produced. In severe cases 
it may be necessary to increase the dose considerably. When urgently 
required morphin should be given hypodermically, one-sixtieth of a grain 
to an infant of six months, to be repeated in two hours if no effect is 
seen. 

Stimulants are often required in severe cases. The prostration is 
great and develops rapidly ; frequently almost no food can be assimilated 
for twenty-four or thirty-six hours, while the drain from the discharges 
continues. The general condition of the patient is the best guide as to 
the time for stimulation and the amount required. Brandy is the best 
preparation for general use. An infant a year old may, as a maximum, 
take half an ounce of brandy, well diluted, in twenty-four hours. Caffein 
and camphor may also be given. While the use of stimulants is indicated 
in many cases their effects are disappointing. Taken by mouth they are 
frequently vomited. It is then necessary to give caffein and camphor 
hypodermically. In cases of extreme prostration and collapse the hot 
bath, mustard to the extremities and sometimes the mustard pack are 
beneficial. 

When acidosis is present as indicated by dyspnea of the "air hunger 
type" or by stupor, alkalis are indicated, especially sodium bicarbonate. 
This may be given by mouth, intravenously or subcutaneously. Enough 
should be given to render the urine alkaline and to keep it so. As there 
is a greatly increased tolerance for alkalis the amount required may be 
large. With a normal infant the administration of fifteen grains of 
bicarbonate of soda is sufficient to render the urine alkaline. With 
acidosis six or eight times this amount may be required. It should be 
given in doses of fifteen to thirty grains every two hours. If vomited, 
it should be given subcutaneously or intravenously. The latter method 
is preferable if the injection can be made through the skin without expos- 
ing a vein. As much as 50 c.c. of a four per cent solution of sodium 
bicarbonate may be given at a time. If a vein can not be found, the solu- 
tion may be injected subcutaneously. This method has the disadvantage 
of requiring a solution 1 which is somewhat difficult to prepare and even 
with all precautions sloughing may result from its use. The injection 
should be repeated with sufficient frequency to maintain the urine alka- 
line. 

The early evidences of acidosis are difficult to recognize clinically; 
il is, therefore, safer to give soda in all severe cases of intestinal indiges- 



*The .solution is prepared by sterilizing a four per cent solution of carbonate 
of soda. This being irritating it is necessary to transform it to the bicarbonate 
by passing carbon dioxid from a Kipp generator or a cylinder through the cold 
solution until it is colorless to phenolphthalein. It may then be used. Solutions 
<>f bicarbonate cannot be sterilized without decomposing. 



ACUTE ILEOCOLITIS 373 

tion in quantity sufficient to maintain an alkaline reaction of the urine. 

With the severe form of the disease, especially in the cholera in- 
fantum type, the great drains of water and salts from the blood may in 
itself be serious. 

Vomiting is usually present which prevents the giving of water by 
mouth; enemata are not' retained. It is therefore necessary in many 
cases to give water subcutaneously. This may be given by hypodermocly- 
sis as described elsewhere in amounts varying from six to ten ounces 
daily. The bicarbonate of soda solution mentioned above may be em- 
ployed or simple saline solution of a strength of eight-tenths of one per 
cent. These injections should be repeated until the cessation of vomiting 
allows sufficient water to be taken by mouth. Their beneficial effect is 
frequently striking. Glucose in three-per-cent strength may be added 
to the saline solution but in the majority of instances the sugar content 
of the blood is within normal limits or even abnormally high. Except 
in prolonged cases therefore the addition of glucose does not seem to be 
indicated. 



CHAPTER VII 
DISEASES OF THE INTESTINES.— {Continued) 

ACUTE ILEOCOLITIS— DYSENTERY 

(Enterocolitis ; Enteritis; Inflammatory Diarrhea) 

The term ileocolitis is a general one, embracing those forms of 
intestinal disease in which true inflammatory lesions are present. Tn 
the types of cases described in the previous chapter nothing more than 
superficial changes occur, while in ileocolitis the pathological process con- 
tinues until there have been produced marked lesions, often involving all 
the walls of the intestine. Sometimes it is impossible, by symptoms, to 
draw a line between them. This is especially true of the cases ter- 
minating in follicular ulceration of the colon. In certain other forms 
of ileocolitis the evidences of a severe intestinal inflammation are often 
manifest from the very outset. This difference is probably due to a 
difference in the character of the infection. The extent of the lesion- 
depends much upon the duration of the process. 

Etiology. — The predisposing causes of ileocolitis are those common 
tc diarrheal diseases in general, and have already been considered. Al- 
though seen with especial frequency in summer, and in children under 
two years old, it may affect those of any aire, and occur- at all Beasons. 



374 DISEASES OF THE DIGESTIVE SYSTEM 

Epidemics arc not uncommon in the early fall months. While usually 
primary, ileocolitis often follows infections diseases, especially measles, 
diphtheria, and bronchopneumonia. It frequently occurs, in institutions 
chiefly, as a terminal infection in infants suffering from extreme mal- 
nutrition or marasmus. All other forms of intestinal disease are predis- 
posing causes. The question of contagion is unsettled; if at all com- 
municable, it is feebly so. When it occurs epidemically a common origin 
seems more probable than that the disease spreads from one patient to 
another. 

The only bacterium that up to the present time has been proven to 
be capable of producing this form of intestinal disease is the B. dysen- 
teriae of Shiga. This organism, or, more properly speaking, this group 
of closely allied organisms, has now been found in all parts of the world 
in a sufficient number of cases to establish its etiological connection with 
ileocolitis. The B. dysenteriae was shown by Shiga, in 1898 and 1899, 
to be the cause of epidemic dysentery in Japan. In 1900, Flexner estab- 
lished its association with tropical dysentery in the Philippines, and in 
1902, Duval and Bassett, pupils of Flexner, demonstrated its presence 
in a series of cases of diarrhea in children at Baltimore. 

This organism is very frequently found in cases showing blood and 
mucus, or much mucus in the stools. Although usually the B. dysenteriae 
is greatly outnumbered by other organisms, it is not uncommon to find 
it in pure culture. A number of minor differences have been found in 
the bacilli from different cases; there are, however, two main groups, 
the division being made by reason of the difference in reaction with 
litmus mannite; one group is known as the "true Shiga," or "alkaline" 
type ; the other, as the "acid" type, 1 which has been most frequently found 
in the diarrheal diseases of children in this country, although the true 
Shiga is occasionally present, and in rare cases they may be associated. 

Whether the B. dysenteriae is present in normal stools of healthy chil- 
dren is still unsettled. Wollstein at the Babies' Hospital failed to dis- 
cover its presence in the stools of 56 normal infants. The B. dysenteriae 
has never been found outside the body; we are therefore entirely ignorant 
both of its habitat and its mode of entry. There are grounds for believ- 
ing that it appears at times among the saprophytic bacteria of the intes- 
tinal contents. 

The role played by other bacteria, especially the streptococcus, in the 
production of the deeper lesions of the intestine may be an important 
one. This appears, however, to be rather in the nature of a secondary 
invasion; but the streptococcus is found at times in such overwhelming 
numbers that it is considered by some authorities to play the chief part 

1 The "acid" type includes the Flexner-Harris, the "Y" type of Hiss and Russell 
and the Strong (Manila) subvarieties. 



ACUTE ILEOCOLITIS 375 

in the production of the lesions. The gas bacillus of "Welch, the bacillus 
pyocyaneus and the other organisms occasionally found in the stools are 
probably of accidental occurrence. 

Lesions.— Tt is surprising that, so far as is known, a single organism 
can excite such a variety of lesions. The nature of the anatomical 
changes apparently depends upon other factors, such as the intensity 
of the infection, the local resistance, and still more upon the duration 
of the disease. The association of other organisms must also he con- 
sidered. 

The nature of the lesions in ileocolitis differs greatly, but their posi- 
tion is quite constant; they affect the lower ileum and the colon. In 
about half the cases only the colon is affected. The lesions of the i leu in 
arc usually limited to the lower two or three feet. 

Acute Catarrhal Ileocolitis. — In the milder cases there is infiltration 
of the mucosa. In the severer cases the submucosa is involved, and the 
infiltration of the mucosa may be so great as to lead to necrosis and the 
formation of ulcers. 

While the lower ileum and the colon are most seriously affected, it is 
not uncommon to find quite marked changes in a considerable portion of 
the small intestine, and even in the stomach. In the cases of short 
duration, the lesions are sometimes more marked in the small intestine 
than in the colon. The mucous membrane is often coated with tenacious 
mucus and may appear somewhat swollen. Congestion is a constanl fea- 
ture, and it may be simply upon the folds of the mucous membrane, 
or about the solitary follicles, or it may be intense and involve I Ik 1 whole 
intestine for some distance. Small hemorrhagic areas are often seen here 
and there, widely scattered. "In the most severe cases there are marked 
thickening and uniform congestion. Hie solitary follicles throughout 
the colon are usually swollen, projecting above the mucous membrane and 
about the size of a pin's head. Peyer's patches may be normal, or they 
may be swollen and congested, or, more rarely, they may be involved 
when the rest of the mucosa appears healthy. The lymph nodes of the 
mesentery are usually swollen and acutely congested. 

In interpreting the microscopical changes found in the mucosa, the 
same precautions must be observed as stated in the previous chapter. 
There is usually loss of the superficial epithelium and of that lining the 
tubular glands at their orifices. The lumen of the tubular glands is 
narrowed from pressure due to the swelling of the tissue which separates 
them, which is partly from edema, and partly from cell infiltration. A 
thick layer of nnicns and round cells, adhering closely to the surface, 
may resemble a pseudo-membrane (Fig. •'!<;). The superficial portion of 
the mucosa may he infiltrated with round cells and crowded with bacteria 
of many kinds; the depth to which this infiltration extends depends upon 



376 



DISEASES OF THE DIGESTIVE SYSTEM 



the severity and duration of the process. In very severe cases there is 
found a dense infiltration of the mucosa and of the submucosa also, which 
in places extends quite to the muscular coat. The lymph nodules of the 
colon are swollen to a greater or less degree, chiefly from an increase in 
the number of lymphoid cells. This swelling may be the most prominent 
feature of the lesion. If the process is sufficiently prolonged, the lymph 
nodules may break down and ulcerate. The changes in the lymph 
nodules of the small intestine and in Peyer's patches are similar to those 
seen in the colon, but are less marked, and are frequently absent alto- 
gether. Ulceration in Peyer's patches is extremely rare. The small veins 







Fig. 36. — Acute Catarrhal Inflammation of the Ileum ; Severe Form. The mucosa, 
C, is everywhere densely infiltrated with round cells, compressing the tubular follicles, 
and in places, L, L, almost effacing them. Upon the surface of the mucosa is a thick 
layer of cells and mucus. Beneath this the epithelial arches, B, B, covering the villi 
can be seen. The lesions are almost entirely of the mucosa. The only changes in 
the submucosa, E, are groups of cells about the small blood-vessels, V, V. History. — 
Infant six months old; moderate diarrhea twelve days; severe symptoms with high 
temperature for six days. There was intense inflammation of the entire colon and 
lower three feet of the ileum. Intestine greatly congested and thickened. Specimen 
is from the ileum. 



and capillaries of the mucosa and submucosa are usually distended with 
blood; small extravasations are very common, and occasionally larger 
ones arc seen. 

Catarrhal inflammation, except in its very severe form, which is not 
frequent, causes no lesions that can not readily be repaired. The most 
persistent change is usually the swelling of the lymph nodules, which 
may last a long time. There is often pigmentation which may occur 
ae striae in the mucous membrane but which is more frequently limited 
to IVyer's patches and the solitary lymph nodes. Under the microscope 
there may be found more or less cell infiltration of the mucosa, but rarely 
any destructive ehanges or new connective tissue. 



PLATE V 




Extensive Superficial Ulceration of the Colon 
Female child nine months old: symptoms of acute ileocolitis of fifteen days' duration; 

temperature, 101° to 104.5° F., and from six to eight stools daily — thin, green, and y< llow, 

but no blood. 

Extensive ulceration throughout the colon, most marked in descending portion, from 

which specimen is taken. 

A A are smatl circular ulcers; B B, larger ones from coalescence of several of these; 

G C, large areas of ulceration, the mucous membrane being almost entirely dcstroved. 



ACUTE ILEOCOLITIS 377 

Catarrhal Inflammation with Superficial Ulceration. — In the most 
severe form of catarrhal inflammation which does not prove fatal in 
the earlier stages, extensive ulceration occasionally takes place; usually 
these ulcers are seen throughout the entire colon, and occasionally a 
few are found in the lower ileum. They generally begin in the mucosa 
overlying the lymph nodules, and while they have a wide superficial area, 
they do not extend deeper than the mucosa. The small ulcers are circular 
and usually show at the center a small granular body — the lymph nodule. 
The larger ulcers result from the coalescence of several small ones, and 
are irregular in shape. They may be two or three inches in diameter. 
Sometimes for a considerable distance a large part of the mucosa may be 
destroyed. Often the entire surface presents a worm-eaten appearance 
(Plate V). On microscopical examination there is seen, in the greater 
part of the ulcer, complete destruction of the mucosa, the submucosa 
being densely packed with round cells quite to the muscular coat. 

Inflammation of the Lymph Nodules — Follicular Ulceration. — Follic- 
ular ulcers are found at autopsy in about one-third of the cases dying 
from diarrheal diseases. They are rarely seen in those which have lasted 
less than a week, and not often before the middle of the second week. 
The average duration of the disease in these cases is about three weeks. 

In thirty-six cases in which follicular ulcers were found at autopsy, 
they were present in the small intestine alone in but three cases; in the 
small intestine and in the colon in six cases; in the remaining twenty- 
seven they were present only in the colon. When in the small intestine 
they were seen only in the lower ileum. Ulceration was seen a few times 
in one or two of the nodules of a Peyer's patch. Ulceration of the large 
intestine involved the whole colon in about half the cases; while in the 
remainder the process was limited to its lower portion. The deepest and 
also the largest ulcers were usually in the descending colon and sigmoid 
flexure. 

In the early stage these ulcers appear as tiny excavations at the sum- 
mit of the prominent lymph nodules. Later, the whole nodule may be 
destroyed, and a small round ulcer is formed from one-twelfth to one- 
fourth of an inch in diameter (Plate VI). These are quite deep and 
have overhanging edges; when closely set they give the intestine a Bieve- 
like appearance. By the coalescence of several of them, larger ulcers 
may form which are an inch or more in diameter. At the bottom of 
these larger ones the transverse striae of the circular muscular coal are 
often plainly seen. Perforation is extremely rare. 

Microscopically the lymph nodules appear swollen, principally from 
the accumulation within them of round cells. This is followed by soften- 
ing, which usually begins at the summit of the nodule and extend- 
downward; the reticulum breaks down, and the cellular contents escape 



37 



DISEASES OF THE DIGESTIVE SYSTEM 



into the intestine (Fig. 37). Softening may begin at the center of the 
nodule, which ruptures like an abscess. The destruction of the whole 
nodule leaves a cavity, which is the follicular ulcer. At first the ulcer 
corresponds in size to the nodule, but infiltration of the adjacent tissue 
soon takes place, which may become necrotic. In this way the ulcer 
extends chiefly in the submucous coat. The lesion is never limited 
to the lymph nodules ; but the extent of the other changes found depends 



rM.f'--L/ ' ''•*»#, ' 




J/oOt: 



Fig. 37. — Lymph Nodule of the Colon in the Early Stage of Ulceration. — Follicu- 
lar Ulcer. The nodule, F, is much enlarged, and is breaking down and discharging 
into the intestine. The other changes are not marked. The superficial epithelium 
is gone; the mucosa, A, shows a slight increase of cells, and in the submucosa, C, nre 
nests of cells about the small vessels, V, V. History. — Delicate child, thirteen months 
old; slight diarrhea four weeks; severe symptoms five days. The colon was filled 
with ulcers one-twelfth of an inch in diameter, one of which is shown in the illustration 

upon the severity and the duration of the process. In cases fatal after 
mi illness of a week or ten days, we usually find only moderate changes 
in the mucosa, and in the submucosa. 

Follicular ulceration of the intestine in infancy usually terminates 
fa 1 ally if the process is an extensive one. In less severe cases recovery 
may take place, the ulcers healing by granulation and cicatrization in the 
course of from four to twelve weeks. It is very doubtful whether sfric- 
fcure ever results from these ulcers in children. Among the very rare 
lesions arc cysts of the colon that are produced by dilatation of some of 
the tubular glands whose orifices have been obliterated. 

A.CUTE Membranous Ileocolitis. — This is the most severe form of 
intestinal inflammation seen among children. The most frequent type 



PLATE VI 




Deep Follicular Ulcers of the Colon 

A delicate child, fourteen months old, sick twelve days; stools green, yellow, brown, 
and watery; no blood; temperature, 100° to 101° F. 

The small intestine was normal; ulcers throughout colon. The specjinen i- from 
descending colon; the ulcers are deep, and most of them extend to the muscular coat. 



ACUTE ILEOCOLITIS 370 

of membranous colitis is that with severe acute symptoms, both consti- 
tutional and local, with a duration of from six to fourteen days. In 
young infants its symptoms and course are very irregular, and ir may be 
found at autopsy when no serious intestinal lesion has been suspected. 

Gross Appearances. — There is visible to the naked eye usually very 
little pseudo-membrane and no deep sloughing. The lesion affects the 
last two or three feet of the ileum and the entire colon, sometimes only 
the colon. It is exceedingly rare to meet with any marked lesions higher 
in the small intestine. The most marked changes are near the ileocecal 






V r~ , ^ 



Fig. 38. — Deep Follicular Ulcer of the Colon. A deep ulcer is shown at F, a smaller 
one at F' . The separation of the mucosa at H is accidental. There is no trace of the 
lymph nodule from which the large ulcer had its origin. The destructive process has 
extended laterally in the submucosa, C, and the mucosa, A, is falling in to fill up the 
space. In the vicinity of the ulcers, the submucosa is densely infiltrated with round 
cells L" , L" , which also are seen in the lymph spaces between the bundles of circular 
muscular fibers, U, L' , and some are seen in the longitudinal muscular coat, L, L. 
History. — Thirteen months old, delicate; continuous diarrheal symptoms for I luce 
weeks. Ulcers found throughout the colon, the largest, one-halt' an inch in diameter. 
The illustration shows one of the small ones like those in Plate VI. 

valve or in the sigmoid flexure and the rectum. Tn the ileum they may 
he quite as severe as in the colon (Plate VTT). The intestinal wall is 
firm and stiff, and is two or three times its normal thickness. II is imi 
thrown into deep folds, as is the healthy intestine when empty. Ii is 
\civ rare to find false memhrane that can he stripped off in patches of 
any considerable size. When membrane exists, the color is a yellowish 
or grayish greem and the surface is often fissured, giving a tabulated 
appearance. In the parts where no pseudo-membrane can be seen. Hie 
surface is usually of an intense red color and is rough and granular, in 
striking contrast to the normal glistening appearance. FTere and there 
small extravasations of blood may be seen. In the regions most affected, 
the normal structures of the mucous membrane the villi. IV 
patches, and solitary follicles — cannot be distinguished. Except in the 



380 DISEASES OF THE DIGESTIVE SYSTEM 

lower ileum the small intestine shows no constant changes, and none are 
usually found in the stomach. 

Microscopical Changes. — These (Fig. 39) are much more uniform 
than the gross appearances. The most characteristic feature is the exu- 
dation of fibrin, which forms a distinct pseudo-membrane upon the 
surface of the intestine ; it may infiltrate the mucosa, and even the sub- 
mucosa. Fibrin is seen under the microscope in parts of the specimen, 
which to the naked eye show no distinct pseudo-membrane, but only a 




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Fig. 39. — Membranous Inflammation of the Colon. The intestine is covered with 
a pseudo-membrane, M, which is composed chiefly of granular fibrin; the mucosa. 
A, is densely packed with round cells, and the tubular follicles have almost dis- 
appeared, traces only being left, at T, T. The submucosa, C, is greatly thickened, 
partly from cells, but chiefly from fibrin, which with a high power is seen to be every- 
where in this coat, as well as the mucosa. Nests of cells are seen in the muscular 
coats at L, L. At F is a lymph nodule covered by pseudo-membrane, but breaking 
down at its center. V, V, are small blood-vessels with nests of cells about them. 
History.— Fourteen months old; ill nine days; temperature 101° to 105° F. ; all stools 
containing blood. Lesions found throughout colon and in lower ileum. Intestine 
greatly thickened. Specimen is from ascending colon, where lesion was especially 
severe. 

granular appearance. In rare cases a fibrinous exudation may be found 
upon the peritoneal covering of the intestine. The pseudo-membrane is 
made up of a fibrinous network containing small round cells, some red 
blood-cells, and numerous bacteria. The mucosa, and usually the sub- 
mucosa, are densely infiltrated with small round cells, which in places 
may be so numerous as to efface the normal elements of the intestine. 
The tubular follicles are in some places quite destroyed, not a vestige of 
them remaining. In other places they are compressed and distorted by 
the accumulation of cells. The great thickening of the intestine is due 



ACUTE ILEOCOLITIS 381 

partly to the cell infiltration, partly to the fibrinous exudation, and 
partly to edema. All the blood-vessels, both in the mucosa and sub- 
mucosa, are gorged with blood, and many small extravasations are seen. 
A necrotic process with the formation of deep ulcers we have uever seen 
associated with membranous colitis. 

Associated Lesions of Ileocolitis. — The most important one is broncho- 
pneumonia. It is found in quite a large proportion of the protracted 
cases, and not infrequently it is the cause of death. There is no evidence 
that it is due to an infection from the intestine, although such a thing is 
possible in septicemic cases. Pulmonary tuberculosis is not infrequently 
met with in hospital cases, having no relation to the intestinal disease. 
Peritonitis is infrequent. We have met with it but once or twice, and 
then it was localized and of the plastic variety. Inflammations of the 
other serous membranes — pleurisy, pericarditis, and meningitis — are all 
very rare. 

The renal lesions of ileocolitis have been the subject of considerable 
discussion, some observers holding that nephritis is a frequent compli- 
cation of the severer forms of diarrhea, while others have held it to be 
rare. The lesions that we have usually found coincide with those de- 
scribed by others, and consist in marked degeneration of the epithelium 
of the tubes with but few glomerular or interstitial changes. Acute 
diffuse nephritis is a very infrequent though sometimes a most serious 
complication. The lesions mentioned as. usually present are properly 
classed as acute degeneration rather than as inflammation of the kidney. 
Degenerative changes may be found also in the heart muscle, the liver, 
spleen, and even in the central nervous system. 

Considerable attention has been given to a study of the blood in 
intestinal inflammations, to determine how frequently and in what 
circumstances a general blood infection (septicemia) from the Intes- 
tines occurs. In the great majority of the cases studied under proper 
precautions the blood is sterile. 

Symptoms. — (1) Catarrhal Cases of Moderate Severity. — The onset is 
usually sudden, often with vomiting, and for twelve, sometimes twenty- 
four hours the symptoms may be those of acute indigestion: vomiting, 
pain, fever, and frequent, thin, green or yellow stools, which are partly 
fecal and contain undigested food. Later the discharges contain blond 
and mucus, are often" preceded by pain and accompanied by tenesmus. 
The stools are very frequent, often every half hour, and proportionately 
small, sometimes less than a tablespoonful being round upon the nap- 
kin after severe straining efforts. The mucus may be clear and jelly- 
like, or it may be mixed with fecal matter. Blood is seen in some i 
in almost every stool, but rarely in dots, usually Btreaking the mucus. 
These stools are almost odorless. After a few days the blood usually 

14 



382 DISEASES OF THE DIGESTIVE SYSTEM 

disappears, or is seen only as traces in an occasional stool; but mucus 
is still present in large quantities. The color of the discharges now 
becomes dark brown or brownish-green. Prolapsus ani is frequent, 
and may occur with nearly every stool. Abdominal pain is present, and 
is often quite intense just before the stool ; frequently there is ten- 
derness along the colon. For the first twenty-four hours the tempera- 
ture is usually high, from 102° to 104° F. During the greater part of 
the attack it ranges from 99° to 102° F. There is considerable prostra- 
tion; the loss in weight is usually marked and continuous; appetite is 
lost ; the tongue is coated and the general appearance of the children in- 
dicates serious illness, although no really grave symptoms are present. 
Convalescence is always slow, and it may be months before the lost weight 
is regained. 

In the milder cases the symptoms point to inflammation of the lower 
part of the colon only. The constitutional symptoms are not at all 
marked. The temperature may not be above 101° F. ; the tongue may 
remain clean and the appetite good; the child may be bright and active, 
and hardly seem at all ill, and yet have from six to eight mucous and 
bloody stools a day. 

The duration of the acute symptoms is usually two weeks, and yet 
in such cases, even though the child was previously in good condition 
and properly treated, recovery is slow. The first symptom of improve- 
ment is generally the disappearance of blood from the stools, which at 
the same time become less frequent, and the pain and tenesmus cease. 
Gradually the stools assume more of a fecal character, but mucus is 
likely to persist for two or three weeks; it may be seen in all stools, or 
only occasionally. In some cases both the mucus and blood disappear 
and the stools become thin, brown, or green, like those of an ordinary 
diarrhea. Relapses are readily excited, but cases such as have been de- 
scribed are rarely fatal except in delicate infants. This is. the most com- 
mon form of ileocolitis which terminates in recovery. 

(2) The Severe Catarrhal Form. — This form of ileocolitis, like that 
just described, is usually primary. The symptoms closely resemble those 
of the membranous variety, and a diagnosis from it is in most of the 
cases quite impossible. The most rapidly fatal case we have seen lasted 
only three days, but the usual duration is from one to two weeks. The 
temperature is steadily high; the stools continue very frequent and 
generally contain blood; there is great prostration, dry tongue, sordes 
on the lips and teeth, and prominent nervous symptoms. Death usually 
occurs from exhaustion and profound sepsis while the acute symptoms 
are at their height. If the patient survives this stage, the case may 
drag on for four or five weeks with a temperature curve much like that 
of typhoid fever, and then terminate in recovery or in death from slow 






ACUTE ILEOCOLITIS 



383 



asthenia, bronchopneumonia, or from an acute exacerbation of the intes- 
tinal symptoms. The autopsy in such cases usually reveals the presence 
of superficial ulcers. If recovery is to be the outcome, after the symp- 
toms have been nearly stationary for a long time, there is seen a gradual 
improvement first in the general and then in the local conditions. Con- 
valescence is very slow, often interrupted by relapses, and it may be 
months before the patient is quite well. 

(3) Follicular Ulceration — Ulcerative Inflammation of the Nodules. 
— Follicular ulceration is often preceded by other forms of intestinal 
disease. It is much more frequently met with in infants over six months 
of age. The great majority of those affected are institutional children 
or those who are in poor condition at the time of the attack. 

To understand the symptoms of these cases, it must be remembered 



DAY 




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Fig. 40. 



-Temperature Chart of Ileocolitis, Fatal on Thirty-fourth Day. Autopsy 
showed follicular ulcers throughout the colon. 



that follicular ulceration is often a terminal process following other forms 
of diarrhea. It may be preceded by one or more acute attacks, or by a 
protracted subacute attack. On account of the feeble resistance of the 
child or the continuance of the exciting cause, the pathological process 
gradually extends to the lymph nodules of the intestine, chiefly the 
colon, which, as already described, pass successively through the stages 
of swelling, softening, and ulceration. The onset of the illness may 
therefore be abrupt, with vomiting and high fever; or gradual, without 
vomiting and with very little fever. 

Vomiting is not a feature of these eases ; but it is often present at the 
onset. Throughout the attack it is easily excited by injudicious feeding 
or medication. The temperature is seldom high, except at first ; its usual 
range is from !>!>" to 101° P.; toward the close, even of fatal cases, it may 
be scarcely above the normal. The accompanying chart (Fig. M>) ie a 
very good illustration of the course of the temperature in cases begin- 
ning abruptly and ending fatally. 

The stools are seldom very frequent, the Dumber being from four 
to eight a day. The most constant feature is the presence of mucus, 



384 DISEASES OF THE DIGESTIVE SYSTEM 

which is mixed with the stools and usually abundant. Blood is not gen- 
erally present, and a large amount of blood is extremely rare. Large 
hemorrhages from ulcers we have never seen. The color of the stools 
is most frequently dark green or brown. Fluid stools are seen only 
during exacerbations. The odor is usually offensive, particularly in pro- 
tracted cases. The microscope shows epithelial cells in great numbers, 
and very often an abundance of small round cells, which may be looked 
upon as the most constant sign of ulceration. 

The failure in nutrition and steady loss in weight are very constant 
in these cases. As emaciation goes on, the skin hangs in loose folds on 
the thighs; it becomes dry and scaly and loses its elasticity, and occa- 
sionally small petechial spots are seen upon the abdomen. The skin over 
the buttocks becomes excoriated, and bed-sores form over the heels, the 
sacrum, or the occiput. The abdomen may be moderately distended, or 
it may be relaxed and soft. Tenderness is not usually present. The 
appetite is lost, and in most cases great difficulty is experienced in induc- 
ing children to take a proper amount of nourishment. Occasionally, 
when there is fever, fluids are taken eagerly. A returning appetite is 
always an encouraging sign. The mouth is often dry, the tongue coated, 
sometimes dry and brown ; there may be sordes upon the lips and teeth. 
Superficial ulcers form upon the mucous membrane of the mouth, and 
often thrush is seen. The urine is usually diminished, high-colored, and 
loaded with urates. Albumin and casts are occasionally present. Barely 
is nephritis severe enough to be a factor in the result. Tenesmus and 
prolapsus ani are uncommon. 

The usual duration of the fatal cases is three or four weeks, but may 
be very much longer; their course is often marked by exacerbations and 
remissions. If recovery takes place, convalescence is always very slow and 
relapses are easily excited. 

Very few of these cases recover completely. Even those who survive 
the primary illness are likely to suffer from intestinal symptoms for 
many months. Fatal relapses are often brought on by injudicious feed- 
ing when the children are apparently almost well. The general health 
is usually so undermined that the patients continue to suffer from all the 
symptoms of malnutrition, and ultimately succumb to an attack of some 
intercurrent acute disease. 

The diagnosis of ulceration is to be made from the case as a whole 
rather than Prom any special symptoms. If a delicate infant, who has 
previously been prone to diarrheal attacks, has green mucous stools with 
low fever, and these symptoms continue with unabated severity for two 
or three weeks, ulceration is probable. If such symptoms continue for 
three or four weeks with steadily failing strength and loss of weight, the 
diagnosis is almost certain. If, on the contrary, after three or four days 



ACUTE ILEOCOLITIS 



385 



of acute symptoms there is improvement in the stools and occasionally 
some which are quite fecal in character, even though it may be a week 
or more before the mucus disappears, we may be quite certain that no 
ulcers have formed. 

(4) The Membranous Form. — This is the gravest form of inflamma- 
tion of the intestines seen in children, and its symptoms are more often 
obscure than are those of any other variety. This is particularly true 
when it affects young infants. There may be at the onset and through- 
out the course of the disease severe local and constitutional symptoms; 
or with well-marked constitutional symptoms, the local symptoms may 
be slight or of very doubtful character, 
so that it is often mistaken for some 
other disease. 

In the' first form it closely resem- 
bles the most severe cases of catarrhal 
inflammation. The disease begins 
abruptly with vomiting, high temper- 
ature, and several large, fluid stools. 
The vomiting does not often continue 
after the first twenty-four hours. The 
temperature is at first from 102° to 
105° F., and its course may be steadily 
high (Fig. 41), or remittent. The ab- 
domen is often tender and sometimes 
swollen. There is severe pain, and at 

times tenesmus, with prolapse of the rectum. This is seen to be intensely 
congested, and sometimes shows patches of pseudomembrane upon its 
surface, thus establishing the diagnosis. 

The stools often resemble those of the catarrhal variety, except that 
blood is more constantly present and usually more abundant, but the only 
positive point of difference is the presence of shreds or flakes of pseudo- 
membrane. If the stools are thoroughly washed with water these may 
be seen as small gray opaque masses, which are then easily distinguished 
from the transparent mucus. Large shreds of membrane are seldom 
seen in children. Both blood and mucus sometimes disappear from the 
stools, which may consist only of dirty water. Under the microscope 
there may be seen epithelial cells, red blood-cells, and round cells in 
great numbers. 

The presence of cerebral symptoms in these cases of membranous 
ileocolitis may lead to great obscurity in the diagnosis. This is mosl 
frequently true at the onset. There may be high temperature, greal 
prostration, vomiting, stupor, delirium, aud even convulsions; and such 
symptoms may for two or three days completely mask the intestinal con- 



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Membranous Colitis: Fatal. 



386 



DISEASES OF THE DIGESTIVE SYSTEM 



dition. As the case progresses, however, the intestinal symptoms come 
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side. But sometimes this is not the case. 

Membranous colitis is also obscure when it affects young infants. 
The prominent symptoms are, ' rather high, continuous temperature, 
usually ranging between 101° and 104° F., but following no distinct 
curve (Fig. 42) ; wasting, which is not rapid but progressive; frequent 
stools, which have no constant or striking characteristics. They are 
usually thin, yellow or greenish in color, often containing no mucus or 
blood. Occasionally for a day the stools may be almost normal in ap- 
pearance. In number they average five or six a day, but often for days 
only two or three. Outside of a hospital where autopsies are regularly 



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Fig. 42. — Temperature Chart op Membranous Colitis. Infant fourteen months 
old, Babies' Hospital. Symptoms for the first two weeks obscure. Intestinal symp- 
toms for the last two weeks only, never very severe; stools four to six daily, generally 
green, thin, with much mucus at times, and once or twice traces of blood. Autopsy: 
No lesion of importance except membranous colitis involving entire colon; a slight 
catarrhal enteritis. 



made these cases are usually overlooked and considered as obscure pneu- 
monia, tuberculosis, septicemia, typhoid, etc. 

The duration of membranous ileocolitis is usually from one to three 
weeks. Death takes place from sepsis, exhaustion, or from complica- 
tions. It is probable that almost every case of the severity described 
terminates fatally when it occurs in an infant. In older children the 
prognosis is much better as to life, but in them the acute attack may 
be followed by the chronic form of the disease. 

Diagnosis. — Ileocolitis is to be distinguished chiefly from typhoid 
fever, intussusception, and meningitis. Typhoid is distinguished by the 
slower invasion, more constant temperature, enlargement of the spleen, 
tympanites, and most of all by the Widal reaction and the eruption. 
Acute colitis should not be confounded with intussusception; yet the 
records of intussusception show that a very large proportion of the cases 
were regarded in the beginning as cases of dysentery. In intussuscep- 
tion, although there is a sudden onset with acute pain, tenesmus, vomit- 
ing, and marked prostration, there is rarely fever. The later symptoms 



PLATE VII 




Membranous Inflammation oj nn. [lei u 
A delicate child, eleven months old; mild diarrhea for fcwo weeks without fever; 

acute severe symptoms for twelve days; temperature, 100° to 102 5° F.; green and mucous 

stools; no blood. 

The lesions involved the last foot of ileum and entire colon. Specimen Lb from lower 

ileum, and shows the abrupt termination of the lesion; the upper pari shows normal 

small intestine; A is a Peyer's patch ; B is the inflamed part of the intestine; it has a rough 

granular appearance and is much thickened. 



ACUTE ILEOCOLITIS 387 

— absolute constipation, tumor, stercoraceous vomiting, and collapse — 
have nothing in common with colitis. The membranous form may be 
confounded with meningitis, and in some cases a differential diagnosis 
is impossible except by lumbar puncture. Marked diarrhea, even 
though the stools are not characteristic, should always make one doubt 
meningitis. 

A diagnosis between the different varieties of ileocolitis is not always 
possible. Follicular ulceration is distinguished by its lower temperature, 
rather subacute course, infrequency of blood in the stools, and by the 
fact that it is usually preceded by diarrheal attacks which are often 
prolonged. 

In the catarrhal form, the symptoms of an acute inflammation of 
the colon are usually manifest from the outset — bloody stools, pain, 
tenderness, tenesmus, and fever. In the membranous variety such symp- 
toms are sometimes seen; but, as a rule, the local symptoms are less 
pronounced, while the constitutional symptoms, especially those relating 
to the nervous system, are usually marked. The course is usually shorter 
and more intense than in the other forms. 

An agglutination reaction of the B. dysenlenae with the serum of 
affected children is usually present. But for general use in diagnosis 
this is not of great assistance. It is subject to considerable variation. 
Moreover, it is seldom present until the end of the first week of the dis- 
ease, by which time the nature of the attack is evident by clinical symp- 
toms. Agglutination in the higher dilutions is seen only with the par- 
ticular type of organism with which the infant is infected. 

Prognosis. — The younger the patient the worse the outlook. The 
prognosis is rendered unfavorable by extreme summer heal and by 
prolonged previous attacks of intestinal disturbance. The outlook i- 
worse in secondary than in primary cases. In a given case bad prog- 
nostic symptoms are: continuous high temperature*, flu* persistence of 
much blood in the stools, and severe nervous symptoms. The prognosis 
is always worse in institutions than in private practice. 

Prophylaxis. — What has been said in a previous chapter regarding 
the general prophylaxis of diarrheal disease, applies equally well to 
cases of ileocolitis. 

Special emphasis should be placed upon flic necessity of energetic 
early treatment of all the milder forms of diarrhea, ami particularly 
the cases of acute intestinal indigestion, in order thai the process may 
be arrested before serious anatomical changes have taken place Equal 
stress should be laid upon the importance of prompl and intelligent 
treatment at the very beginning of the cases with a Bndden onset. 

Hygienic Treatment. — The general plan recommended in the pre- 
vious chapter should be followed here. A change of air is desirable for 



388 DISEASES OF THE DIGESTIVE SYSTEM 

most cases as soon as the acute inflammatory symptoms have subsided. 
In the protracted cases which drag on a subacute course, this change 
will often do more than anything else. Plenty of fresh air is necessary 
in all cases. The indications for bathing are the same as in other cases 
of acute diarrhea. It is undesirable to crowd these patients in institu- 
tions, as they always do better when separated. 

The diet during the acute stage should be the same as in other forms 
of acute diarrhea. In the protracted cases the diet presents great dif- 
ficulties, as the children have little or no appetite, and soon come to 
refuse everything in the shape of food that is offered. In infancy, for 
the first day or two only, barley or rice water or weak tea should be 
given. As soon as the vomiting ceases protein milk may be given in 
the manner described in the previous chapter. Buttermilk may be used 
as a substitute if protein milk cannot be obtained, but is not so effica- 
cious. Especially to be avoided, not only in the acute stage but during 
convalescence, are cream, all top-milk mixtures, and also the malted foods. 
Infants, when very ill, are much more likely to take too little than too 
much food. A careful record should be kept of the amount actually 
taken in each twenty-four hours. In no case should food be given oftener 
than every four hours, water and stimulants being allowed between the 
feedings. In older children the diet during the acute stage should be 
much the same as in infants, but to them junket from which the whey 
has been carefully strained may also be given with a spoon. At a later 
period, rare scraped beef, kumyss, buttermilk, skimmed milk, and zoo- 
lak will be found useful, and during convalescence, eggs, boiled milk, or 
milk gruel made with rice or barley. Special care should be given to 
the diet for a long time. For months after an acute attack the intes- 
tines are very easily deranged. Relapses are excited by changes in the 
temperature, by great fatigue or exhaustion, but most of all by improper 
feeding. Especially in older children should such articles as cream, 
corn, tomatoes, green vegetables, and all fruits be withheld for a long 
time. 

Medicinal and Mechanical Treatment. — Cases, the early stage of 
which is marked by vomiting and thin diarrheal stools, are to be man- 
aged at the outset according to the plan outlined in the previous chapter, 
viz., purgation, irrigation of the colon, and stopping all food. Castor oil 
should be administered at the outset — one dram at six months, two 
drams at one year, and half an ounce at four years. The salines 
may be used as described in the previous chapter. If the stomach is at 
all irritable, calomel, one-fourth grain every half-hour for four doses, 
may be substituted. Opium is usually required on account of the pain, 
tenesmus, and great frequency of stools. The dose should be regulated 
by (lie severity of these symptoms. The deodorized tincture and paregoric 



ACUTE ILEOCOLITIS 389 

are, we think, preferable to other preparations. Repeated small doses are 
better than a single large dose. It is very important that opium should 
be withheld for at least twelve hours after the initial purgative. 

As the pathological process is principally in the colon, and most 
severe in the lower half of the colon, it can often be much more effectively 
treated by injections than by drugs given by the mouth. Irrigation of 
the colon is one of our most valuable means of treatment in these cases. 
For general purposes a saline solution at 100° to 104° F. should be 
employed. One or two quarts should be used for each irrigation. The 
solution should be injected high into the colon through a rectal tube, 
and early in the disease repeated at least twice a day. When the tenes- 
mus is very great and blood abundant, small injections of either hot 
water (106° to 110° F.) or ice water may be used, and later astringent 
injections. 

The most useful astringent is tannic acid of which one dram may 
be added to a pint of hot water. Whether injections are to be used 
regularly or not will depend much upon the patient. If they are well 
borne, they may be given once or twice a day during the attack; but if 
at every attempt to give them the child struggles, screams, and resists, 
they may do more harm than good. Complete rest is a very important 
part of the treatment. 

For cases not influenced by the measures mentioned, or those not 
seen at the outset, bismuth should be tried, but it is of no use whatever 
unless large doses are administered. From two to four drams of the 
subcarbonate should be given in twenty-four hours to a child two years 
old, and proportionate doses to older children. This may be suspended 
in mucilage. Tenesmus and pain are sometimes relieved by the injection 
of three or four ounces of a starch solution to which from five to ten 
drops of laudanum are added. Severe tenesmus, when not controlled 
thus, and when associated with prolapsus ani, is sometimes immediately 
relieved by a suppository containing cocain. Xot more than one-fourth 
grain should be used for a child of three years. 

Although a serum has been produced which protects animals against 
inoculation with the B. dysenteriae its use in the treatment of the vari- 
ous forms of ileocolitis in children has not been followed by any very 
striking benefit. 

Alcoholic stimulants are needed in many cases. They are indicated 
by a weak pulse, cold extremities, and greal general prostration, no 
matter at what stage in the disease these symptoms are Been. Brandy 
is usually to be preferred. Generally not more than fifteen or twenty 
drops every three hours should he given to an infant of one year. Brandy 
should always be well diluted. 

In cases where symptoms have lasted two or three weeks, and the 



390 DISEASES OF THE DIGESTIVE SYSTEM 

active ones have subsided, when the temperature is scarcely above 100° 
F., and the stools reduced to four or five a day, it is wise to stop all 
medication and attend only to the feeding, with irrigation of the colon 
every two or three days. One is often surprised at this stage to find 
that patients do better without drugs than with them. The prevailing 
tendency is to overdose cases of this type. No greater mistake is made 
than to give these children week after week the various diarrhea mix- 
tures, with the expectation that ultimately the formula will be found 
which exactly meets the requirements of the particular case. The essen- 
tial and important part of the treatment consists in injections, careful 
feeding and change of air. Astringent enemata, however, are of some 
value; they should not be given continuously but from time to time 
should be omitted for several days. Cases are not infrequently seen 
where the constant use of such injections is an important factor in keep- 
ing up the production of mucus. The colon should first be washed 
with a large amount of a tepid salt solution and then four or five ounces 
of the astringent solution injected and held in place by compressing the 
buttocks for half an hour. The patient should be placed in the best 
possible surroundings ; in no disease is a change of air more to be desired 
than in this. They should be in the open air as much as possible but 
should be kept warm for their temperatures quickly fall to subnormal. 
The dangers of relapses and acute exacerbations continue long after the 
primary attack has subsided. 



AMEBIC COLITIS 

Amebic colitis is rare in children in this country ; it is particularly so 
in infants, probably owing to the fact that nearly all the water taken 
at this age is boiled. Most of the cases in children thus far reported 
have been observed in warm climates, although Amberg has recorded 
five which occurred in Baltimore, the youngest child being two years and 
eight months old. 

The symptoms in the few cases that have been reported in children 
have differed in no important particular from the disease as seen in 
adults. In exceptional cases the onset may be abrupt and the attack 
may run an acute course, terminating fatally in two to three weeks. 
Such cases are characterized by much abdominal pain and tenderness, 
frequent mucous and bloody stools containing amebae, and some fever, 
which, however, seldom reaches 102° F. 

More frequently this acute onset is followed by a subacute or chronic 
form of the disease, or the disease may be subacute from the beginning. 
The protracted cases are those most frequently seen. They are very 



TUBERCULOSIS OF THE INTESTINES 391 

obstinate to treatment. Periods of constipation and apparent recovery 
often alternate with exacerbations in which the bloody and mucous 
stools return, with pain, tenesmus, and slight fever. The duration may 
be from a few months to one or two years. Death may finally occur 
from exhaustion with extreme wasting, or from some complication, such 
as hemorrhage, abscesses of the liver being very rare in children. The 
diagnosis from other forms of colitis is made only by the discovery of 
pathogenic amebae in a freshly voided stool. 

The general treatment is the same as for other forms of acute or 
subacute colitis. The special treatment for the purpose of destroying 
the amebae locally is the use of injections of quinin which may be em- 
ployed in solutions varying in strength from 1 to 5,000 to 1 to 250. 
Eecently subcutaneous injections of emetin hydrochlorid have been used 
for amebic colitis with very favorable results. Emetin should be given 
in doses of gr. 1/12 to gr. 1/-4 depending upon the age of the child. 
The dose should be repeated two or three times at intervals of a day or 
more. The drug is a very powerful one and is to be used with caution. 



AMYLOID DEGENERATION OF THE INTESTINES 

This is rarely met with in infants. It is not so infrequent in older 
children, where it is associated with amyloid changes in the liver, spleen, 
and kidneys, usually as a result of prolonged suppuration in connection 
with bone tuberculosis. It is sometimes met with in syphilis. The ileum 
is the part of the intestine most affected. The process begins in the 
walls of the arterioles and capillaries, particularly of the villi, and later 
involves the vessels of the submucosa ; subsequently the epithelium may 
be affected. The mucous membrane in these cases is pale, somewhat 
translucent. The condition is recognized by the application of the iodin 
test; the affected villi become of a brownish-red or mahogany color. 

Amyloid degeneration produces no definite symptoms. Diarrhea is 
frequent but by no means constant. The anemia and waxy cachexia 
which are present are probably dependent much more upon the associated 
lesions of the liver and kidneys than upon the changes in the intestines. 



TUBERCULOSIS OF THE INTESTINES WD MESENTERIC LYMPB 
NODES (MESENTERIC GLANDS 

These two conditions are usually, but not invariably, associated, and 
may be conveniently considered together. 

Frequency. — In a series of 38G autopsies upon tuberculous cases from 



392 DISEASES OF THE DIGESTIVE SYSTEM 

our hospital records, the intestines were involved in -10 per cent. The 
great majority of the patients were under three years of age. In 131 
autopsies upon tuberculous cases published in the Pendlebury Hospital 
Keports, the intestines were involved in 50 per cent. These patients 
were mainly between four and fourteen years old. In 209 autopsies 
upon tuberculous children, chiefly infants, reported by Miiller, the intes- 
tines were involved in 28 per cent. In 1,346 autopsies collected by 
Biedert there were intestinal lesions in 31.6 per cent. Intestinal tuber- 
culosis is most common from the third to the eighth year. The mesen- 
teric lymph nodes are more frequently involved than are the intestines, 
though the two are usually associated. They were tuberculous in 59 
per cent of the Pendlebury cases; and in 178 recent autopsies at the 
Babies' Hospital upon tuberculous patients, published by Bartlett and 
Wollstein, these nodes were involved in 63 per cent ; in 10 per cent they 
were apparently the oldest tuberculous lesions. 

Etiology. — While it is no doubt possible for infection of the mesen- 
teric nodes to occur through the general circulation, this is exceptional. 
In the great majority of cases infection takes place from the intestines; 
i. e., these are examples of tuberculosis by ingestion rather than by in- 
halation. The bacilli in the intestinal tract may be derived from food 
or from sputum which has been coughed up and swallowed. Of 96 cases 
of abdominal tuberculosis of all varieties in children under sixteen years, 
studied by Park and Krumwiede, the infection was of the bovine type in 
52, and the human type in 44 cases. Of these children, 71 were under 
five years and 25 between five and sixteen years. The proportion of 
bovine infections was slightly larger in the younger group. Primary in- 
testinal tuberculosis in this country is relatively infrequent. When it 
does occur, however, it is more often due to a bacillus of the bovine than 
of the human type. The inference is probably justified that in cases 
of bovine infection, tuberculous milk was the source of the infection. 
The intestinal lesions most often found in infants and young children 
are mild in character and are usually associated with and secondary to 
an advanced pulmonary lesion. They are doubtless due to swallowing 
tuberculous sputum. In such cases the human type of bacillus is found. 

Lesions. — Intestines. — The usual seat is the small intestine, chiefly 
the jejunum and lower ileum. With extensive disease the large intes- 
tine may also be involved, most frequently the cecum, and exceptionally 
it alone may be affected. Tuberculous ulcers may be found in the 
appendix. 

The early deposits appear as tiny yellow nodules, not numerous but 
widely scattered and generally affecting Peyer's patches. Usually, how- 
ever, ulcers are present, and often only ulcers are seen. Their size and 
number vary greatly; there may be only five or six tiny ulcers, or there 



TUBERCULOSIS OF THE INTESTINES 393 

may be forty or fifty, the largest being two or three inches in diameter. 
They very frequently involve Peyer's patches. The typical tuberculous 
ulcer is of irregular shape, with rounded borders and with its longest 
diameter at right angles to the intestinal axis. When large, it may nearly 
encircle the gut. The ulcers are excavated ; they have overhanging, infil- 
trated edges of a deep-red color. The surface is covered with granula- 
tions. In those which have partially healed a distinct puckering of the 
intestine occurs, which is especially noticeable upon the peritoneal sur- 
face. The small ulcers involve the mucosa only ; the larger and older ones 
the submucosa and the muscular coats, and not infrequently also the 
serous coat. Perforation may occur, but rarely into the general perito- 
neal cavity, as a localized plastic inflammation precedes it. There may be 
adhesions of adjacent intestinal coils, and fistulae may form, owing to 
ulceration at the point of contact. With these severe cases there is always 
associated more or less extensive tuberculous peritonitis, frequently of 
the ulcerative variety. Like other tuberculous processes, the infiltration 
and ulceration may cease at any stage, and cicatrization follow. If the 
ulcers have been large ones, there is always some narrowing of the lumen 
of the intestine. Stricture is rarely seen because most of the children die 
from the general disease before it has had time to occur. Monti has re- 
ported a case of obstruction at the ileocecal valve, due to an old tubercu- 
lous cicatrix, in an infant of twenty-one months. One has come under 
our observation in a child of nine years, in which the obstruction was in 
the colon, just beyond the ileocecal valve. 

Mesenteric Lymph Nodes. — Usually these tuberculous lymph nodes 
are from half an inch to an inch in diameter; occasionally they may 
reach the size of a hen's egg. From a fusion of several of them, tumors 
of considerable size may be formed. We have seen one such mass as large 
as the head of a child at birth. 

The process is the same as that which occurs in other lymph nodes 
of the body. There is a tuberculous inflammation, followed by caseation, 
softening and abscess, or by calcification. Localized peritonitis is found 
in all the marked cases; this is usually plastic, but may be suppurative 
when due to the rupture of an abscess. Pressure upon the vena cava 
may lead to dropsy in the lower extremities. Ollivier has reported a 
in which thrombosis of the vena cava occurred. Pressure upon the portal 
vein may lead to ascites and dilatation of the superficial abdominal veins. 
There may be pressure upon the thoracic duct. 

Symptoms,. — The symptoms of intestinal tuberculosis are exceedingly 
irregular. Ulcers are very frequently found at autopsy when there have 
been no marked intestinal symptoms; this is especially true of the Bmall 
ulcers usually seen in infants. On the other hand, diarrhea is not un- 
common in cases of advanced general tuberculosis where DO 



394 DISEASES OF THE DIGESTIVE SYSTEM 

present. It is the most frequent symptom of ulceration, and may be 
exceedingly obstinate. The stools do not differ essentially from those in 
protracted cases of ileocolitis except in the occurrence of hemorrhages 
and in the presence of tubercle bacilli. Hemorrhages are not very fre- 
quent, but they may be so large as to be the cause of death. This oc- 
curred in one of our cases, an infant nine months old, the blood coming 
from a single ulcer in the ileum. Hemorrhage is more common in older 
children. In some cases localized abdominal pain or tenderness is pres- 
ent. In advanced cases the symptoms of intestinal ulceration are usually 
mingled with those of peritonitis, and there are also present the en- 
larged mesenteric lymph nodes, which may aid in the diagnosis. In the 
majority of cases, these nodes are recognized only by deep palpation. A 
rectal examination may give additional information. The tumors are 
generally felt as irregular nodular masses, lying close against the spine, 
not movable, and sometimes tender on pressure. Other tumors from 
deposits in the peritoneum may be present anywhere in the abdomen; 
they may be superficial or deep. The other symptoms are due to the 
complications already mentioned and to tuberculosis elsewhere. 

Diagnosis. — The only positive evidence of intestinal tuberculosis is 
the discovery of the bacilli in the stools. They are here to be carefully 
differentiated from smegma and other forms of acid-fast bacilli. In the 
absence of such evidence, the disease is differentiated from simple ileo- 
colitis, first, by the signs of tuberculosis elsewhere in the body, espe- 
cially in the lungs, these being almost invariably involved; secondly, by 
the slow onset and gradual development of the symptoms, while in ileo- 
colitis an acute attack has almost invariably preceded. Large hemor- 
rhages should suggest tuberculosis. A positive reaction to the tuberculin 
skin test is of much assistance in diagnosis, as is also the presence of 
palpable mesenteric glands. 

Prognosis. — This depends altogether upon the extent of the tubercu- 
lous disease elsewhere, as it is extremely rare for the intestinal lesion to 
be the cause of death. Once formed, the ulcers probably remain, cica- 
trization being very rare, and then only partial. 

Treatment. — The only symptom which ordinarily demands treatment 
is the diarrhea. When severe, this is to be managed much as in cases 
of ileocolitis, except that irrigation of the colon is, of course, not called 
for. The chief reliance must be upon diet. Bismuth and opium may 
diminish the peristalsis somewhat. No drugs can affect the process. 



CHRONIC INTESTINAL INDIGESTION 395 

CHAPTER VIII 

DISEASES OF THE INTESTINES— {Continued) 

CHRONIC INTESTINAL INDIGESTION 

The diagnosis of chronic intestinal indigestion is frequently made 
when it is not the digestion of the child but the character of the food 
which is at fault. The term should be reserved for those cases in which, 
with proper feeding, there are marked and persistent evidences of dis- 
turbance in intestinal digestion, usually with great retardation in physi- 
cal development. 

Chronic intestinal indigestion is especially common in children from 
the first to the fifth year. 1 It is seldom seen after that time. In a small 
proportion of cases it is apparently the result of a constitutional weak- 
ness. Xursing infants or infants who have been artificially fed during 
the first few months in a manner that cannot be criticized and who have 
thrived fairly well may, when the change to solid food is made, be quite 
unable to digest this or may even gradually manifest an inability to 
digest and thrive upon cow's milk however modified. 

Some cases are clearly the result of improper feeding. With bottle- 
fed infants this is usually the giving of too great proportions of fat. 
With children taking solid food the trouble usually arises from giving 
this too early or in too large quantities, especially when the food has been 
improperly cooked, such as cereals, vegetables, and especially potato. But 
the most frequent cause of the condition is a previous severe or pro- 
longed attack of diarrhea or dysentery from which the child seems never 
to have entirely recovered. Those who have previously been delicate or 
who have had prolonged digestive disturbance before the acute attack are 
particularly liable to be affected. The condition is seen in all grades of 
society but more commonly in the middle or upper classes, for among 
the very poor indiscretions in diet are likely to precipitate attacks of 
acute indigestion which may be fatal. 

There are no characteristic pathological changes other than a dilata- 
tion of the small and large intestine chiefly the latter. In some cases 
this may be extreme. Children who are the subjects of chronic intestinal 
indigestion seldom die from the condition itself, but usually from some 
acute process engrafted upon it, chiefly of the lungs or gastro-intestinal 
tract. There are then found only the lesions of the terminal infection 
or condition. 

Prolonged disturbances in intestinal digestion during the first year have 
been considered under Difficult Feeding Cases. 



396 



DISEASES OF THE DIGESTIVE SYSTEM 



Symptoms. — The clinical picture which these cases present is a very 
common one, and the symptoms are quite uniform. The patients are 
generally very thin, with small extremities, a small amount of subcu- 
taneous fat, and a large protuberant abdomen (Fig. 43). The size 
of the abdomen is perhaps the most striking feature of the condition. 
This is partly due to dilatation of the small intestine, but chiefly to dila- 
tation of the colon which is regularly present in this condition. It 

occurs partly as the result of an excessive 
fermentation of food and partly from the re- 
laxed condition of the muscular coats of the 
bowel. There is no hypertrophy and no ul- 
ceration. Dilatation of the intestine is fur- 
ther favored by a similar condition of the 
muscular walls of the abdomen which in 
marked cases become extremely attenuated, 
almost transparent. This relaxation is to be 
attributed partly to the poor nutrition and 
partly to the constant pressure from within. 
The colon is often dilated to a diameter 
of three or four inches, as shown by X-ray 
examination, and sometimes even more than 
this. An erroneous diagnosis of Hirsch- 
sprung's disease is often made in such cases. 
The circumference of the abdomen may be 
several inches greater than that of the chest. 
Tympanites is constantly present although 
much gas may be passed per rectum. There 
is a marked tendency for the tympanites to 
increase during the day time and to diminish 
at night so that the variation in the circum- 
ference of the abdomen is usually two or 
three inches and sometimes as much as four 
or five inches in twenty-four hours. This 
variation is of assistance in differentiating the condition from tuber- 
culous peritonitis with which it is frequently confounded. Such chil- 
dren are pale, anemic, sallow in complexion and haggard looking; they 
have dark rings under the eyes; they are fatigued on slight exertion; 
they are very cross, irritable, and emotional to an unnatural degree. 
They are hard to amuse, hard to control, and altogether exceedingly 
difficult patients to deal with. Their growth is retarded if the symp- 
toms have lasted long. They are much below the average in height 
and weight, but mentally often quite precocious. One of our patients 
at three years weighed twelve and a half pounds and was twenty-nine 




Fig. 43. — Chronic Intestinal 
Indigestion. — Patient four 
years old ; symptoms of three 
years' duration, following 
attack of acute ileocolitis. 
Height, 34 inches; circumfer- 
ence of abdomen, 22| inches; 
weight, 24 pounds. 



CHRONIC INTESTINAL INDIGESTION 397 

inches tall and another patient at five years weighed twenty-two pounds 
and was thirty-three inches tall. The sleep is always unnatural and 
disturbed ; and at night the children toss about their cribs, waking fre- 
quently, crying out and often grinding their teeth. They perspire very 
readily, and suffer from cold extremities. 

The bowels alternate between constipation and diarrhea, the former 
being more frequently present. At such times the stools are gener- 
ally of a light gray color or nearly white. The odor of the stools is 
usually extremely foul. With diarrhea the stools are often not very 
frequent, not exceeding four or five a day, but they are large, gray, 
green, or brown in color, acid in reaction, often frothy, offensive, and 
always contain undigested food. A stool in many cases is immediately 
excited by the taking of food. From time to time, in many patients, 
large quantities of mucus are passed; in some cases this comes to be a 
constant feature of the disease. A striking feature is the large size of 
the stools in proportion to the amount of food taken. The chemical 
examination of these stools when cow's milk is taken, shows that the chief 
solid constituent is fat which frequently forms as much as GO to 70 per 
cent of the dried matter of the stool, as compared with the normal of 
20 to 40 per cent. The carbohydrates which are taken are largely broken 
down by the excessive fermentation which takes place in the intestinal 
tract. Large quantities of gas are expelled. Pain is not a very common 
symptom, but discomfort from the great tympanites is frequent. The 
appetite is capricious and usually poor, though some patients have a 
voracious appetite and will eat everything offered. The tongue is usually 
clean and the breath is not offensive unless the stomach is also affected, 
when the tongue may be coated. 

The nervous symptoms which these patients present are exceedingly 
varied, and often of the most puzzling character. In some cases there 
are. from time to time attacks in which they are so severe and so per- 
sistent as to lead to the diagnosis of organic disease of the brain. In 
addition to the condition of general nervous irritability, there may be 
tetany, fainting attacks resembling somewhat the seizures of petit mal, 
exaggerated reflexes, attacks of dulness or sometimes stupor, with irregu- 
lar pulse and respiration and other symptoms strongly BUggestive of 
tuberculous meningitis. Convulsions are not uncommon. They are 
usually accompanied by fever, and may be repeated at intervals of a 
few minutes. There is almost no end to the combinations of nervous 
symptoms which these patients may present. The skin shows frequently 
eruptions of erythema or of urticaria. 

Most of these cases are without fever; but in some a slighl fever is 
present for weeks at a time, the temperature usually varying between 
99° and 101.5° F. Occasionally it may rise to 102° or L03 I', during 



398 DISEASES OF THE DIGESTIVE SYSTEM 

an acute exacerbation in the symptoms. The urine of most of these 
patients contains a great excess of indican and the amount present 
often fluctuates regularly with the nervous symptoms. The weight may 
remain stationary or there may be a gradual loss for some time. When 
improvement takes place the gain is apt to be rapid but very irregular. 
Great fluctuations in weight are characteristic of this condition and 
are to be explained by retention and loss of water. Attacks of general 
edema with rapid gain in weight are occasionally seen. Intercurrent 
attacks of acute indigestion, with diarrhea and sometimes also vomiting, 
are frequent and easily excited. Occasionally there are seen attacks of 
intercurrent intestinal infection with the dysentery bacillus, or other 
organisms. 

The course and duration of these symptoms are indefinite. The 
milder cases if recognized early and promptly treated often recover in 
a few months, though careful feeding must be continued for a long time 
to prevent relapses. The severe cases under the most favorable cir- 
cumstances last many months and usually several years. In those which 
progress favorably, improvement is usually first seen in the digestive 
symptoms, next in the nervous symptoms and last of all in the weight. 
In the most severe forms, if untreated, the patients gradually waste 
until they die from exhaustion, or fall easy victims to any acute disease 
which they may happen to contract. There is but little tendency to spon- 
taneous recovery. 

Herter has called attention to a type of this disease associated with 
marked arrest in growth to which he gave the name Intestinal Infantil- 
ism. In several such cases studied he found a failure of retention of 
calcium and magnesium salts over a prolonged period of time. To this 
he ascribed the arrested development of the skeleton. Associated with 
this, there were present evidences of excessive intestinal putrefaction. 
The bacteriology of the condition he believed to be characteristic, viz., 
a preponderance of the B. bifidus^ with great diminution or entire absence 
of the B. coli. 

Prognosis. — This depends upon the duration of the symptoms, the 
general condition of the patient at the time treatment is begun, and 
upon how thoroughly it can be carried out. The symptoms, in the 
great majority of cases, have existed for several months at the time the 
case comes under observation. Generally, the greater the mistakes in 
feeding* have been, and the greater the violation of hygienic and dietetic 
rules, the better the prognosis. A child who has developed chronic in- 
testinal indigestion of a severe type, in spite of the fact that the hygienic 
surroundings were good, and when the dietetic errors were not flagrant, 
is no! nearly so hopeful a subject for treatment as one whose hygienic 
surroundings have been poor and whose diet has been especially bad. 






CHRONIC INTESTINAL INDIGESTION 399 

In cases like the latter, a removal of the causes and the institution of 
proper methods of treatment almost invariably result in immediate and 
striking improvement, unless the general vitality of the patient has 
been reduced to a very low point. In the other cases where the mistakes 
have been less marked and the condition is due more to constitutional 
than to local causes, the improvement is slower and less striking. Thus, 
as a rule, hospital patients improve more rapidly than those seen in 
private practice. 

Treatment. — In no class of cases that the physician is called upon to 
treat are results more satisfactory than in many of those of chronic in- 
testinal indigestion, when intelligent cooperation can be secured. But 
the reverse is also true and no cases are more unsatisfactory than these 
when intelligent cooperation cannot be secured. Treatment is very 
difficult at best; recovery is a very slow process and the periods of ex- 
acerbation of symptoms that occur with almost every case are exceed- 
ingly trying to anxious parents and relatives. If the parents themselves 
are lax in discipline, and are unable to control the child, an efficient 
trained nurse should be secured, into whose hands the exclusive manage- 
ment of the child should be placed. In any case it should be understood 
that the duration of the symptoms is likely to be from one to two years 
and may be much longer. The adoption of a consistent plan of treat- 
ment continuously carried out for a long period is indispensable to 
success. 

The essentia] part of the treatment is diet and general manage- 
ment. It should be remembered that the condition is in most cases 
primarily one of fat indigestion and intolerance. To this there is soon 
added intolerance of carbohydrates and often the latter becomes the 
prominent feature. When there is intolerance of both carbohydrates 
and fats, it is apparent that there can be no gain in weight. The best 
that can be done with these patients is to keep them for a long time upon 
a diet made up almost entirely of protein food. On this one should be 
content if the weight remains stationary or if there is but a slight loss. 
As the digestive condition improves, fats or carbohydrates, according 
to the tolerance, can gradually be added to the diet — at first only in 
very small amounts. In most cases the conditions must he mci em- 
pirically and many mistakes and consequent relapses arc likely to 
occur. 

At the outset the most important thing is to stop all starchy l'<><>d 
for a considerable time, and put the patient upon a diet consisting only 
of rare beef, beef juice, junket without whey, buttermilk <<r protein milk. 
Skimmed milk is well borne by only a limited Dumber. Alter Borne 
improvement has occurred carbohydrates may lie added, hut wry gradu- 
ally beginning with small quantities (not more than one tablespoonful 



400 DISEASES OF THE DIGESTIVE SYSTEM 

a day) of well-cooked cereal. The number of feedings should not be 
more than four a day during the second year, and three or four a day 
for children during the third and fourth years. These should always be 
at regular intervals, and nothing whatever given between meals. The 
meat should be rare scraped beefsteak or lamb chop ; from one to three 
tablespoonfuls may be allowed once a day. The white of egg may be 
given early, and after a time, the whole of a hard-boiled egg very finely 
grated. 

After improvement has been going on for two or three months, bread 
may be added, at first in small quantities and once a day. This should 
preferably be stale, cut thin and dried in the oven until it is crisp, and 
given without butter. Mutton, chicken, or beef broth, without vegetables, 
may be given occasionally in the place of one of the milk feedings. After 
this diet has been kept up for three or four months, if improvement con- 
tinues, one of the green vegetables thoroughly cooked and strained may 
be added once a day. A striking feature of these cases is their marked 
intolerance for sweet cow's milk. This must be withheld for a long 
period. This restricted diet should be continued for at least a year or 
until all the symptoms have disappeared. Potato should be forbidden 
for a long time. A few of the patients can take olive oil when they can- 
not tolerate any other form of fat. This may be tried very carefully, 
beginning with one teaspoonful a day. 

Intestinal irrigation is occasionally useful for brief periods in some 
cases in which there is much mucus passed; no astringents, but only 
a warm saline solution should be used. But it should not be forgotten 
that continued irrigation often keeps up the production of mucus, and 
also that the introduction of large amounts of water may increase the 
intestinal distention. 

The constipation can sometimes be controlled by the diet alone; but 
in most cases drugs are needed also. As laxatives in this condition prep- 
arations of rhubarb, or cascara and the compound licorice powder are 
serviceable. On account of the great tendency to abdominal distention 
due to excessive fermentation and atony of the intestinal walls the bowels 
must be kept well emptied. Most patients do better when two stools 
a day are secured, the second if necessary by an enema, but the frequent 
use of large intestinal injections is to be avoided. Abdominal massage 
is of much benefit in most cases. 

Drugs directed against the process of putrefaction are extremely 
unsatisfactory even in older children and are not to be recommended. 
Of Little value also is the administration of the various digestive fer- 
ments. General tonics are sometimes useful during convalescence and 
apparently assist in the improvement of the general condition, but 
during acute exacerbations their use should be interdicted. Nux vomica 



INTESTINAL COLIC 401 

is the best combined with some mild preparation of iron. Cod-liver oil, 
particularly in the early stage, is badly borne. 

E elapses are easily excited by indiscretions in diet, and parents 
should be impressed at the very beginning with the necessity of adhering 
rigidly to the diet prescribed for a long period. It vefy often happens 
that the improvement which is seen after one or two months of careful 
treatment is so marked as to lead the parents to the belief that a cure 
has been accomplished, so that they relax their vigilance and allow im- 
proper articles of food which are almost certain to induce a relapse. 
If the case is an aggravated one, and the symptoms of long standing, it 
is wise to tell parents at the outset that a year's treatment is the mini- 
mum in which anything permanent can be accomplished. 

The general treatment of the patient must not be overlooked. Proper 
clothing, regular exercise in the open air, cool sleeping rooms, massage 
and, when the condition is such as to permit it, sponging every morning 
with cool water are all of very great importance. An elastic abdominal 
bandage giving moderate support not only adds to the comfort of these 
patients but to some degree prevents the excessive distention likely to 
occur on account of the loss of muscular tone in the abdominal walls. 
The improvement in the nervous symptoms of the patient is often one 
of the first things noticed. From an irritable, fretful, peevish child the 
patient is sometimes totally changed in disposition in a few weeks, so as 
to become quiet, affectionate, docile, and playful. 



INTESTINAL COLIC 

The term colic is applied to any severe paroxysmal pain occurring in 
the intestines. It may be due to many causes. The colic of load and 
arsenic poisoning are both very rare in children; but colicky pains arc 
present in appendicitis, intussusception, ileocolitis, and, in fact, in all 
the severe forms of intestinal inflammation. Colic may be due to swal- 
lowing certain substances, especially foreign bodies and the seeds of 
fruits; and in rare cases it may be excited by the presence of round- 
worms when they are numerous. In all the conditions mentioned, colic 
is only one of the symptoms, although it may be a very prominenl one. 

The peculiar colic of infancy is clearly caused by spasm of the mus- 
cular wall of the intestine. It is a heightened reflex from irritation of 
which we have many other illustrations at Ibis period of life. The 
cause of the irritation is usually the presence of some undigested food 
in the intestine. Colic is therefore essentially a Bymptom of indigestion. 
Flatulence and colic are very often, but not always, associated. Colic 
is always increased by the coexistence of constipation, which in many 



402 DISEASES OF THE DIGESTIVE SYSTEM 

cases is its sole cause. Almost any of the elements of the food may give 
rise to colic. 

Sugars and starches produce it by causing excessive fermentation 
and flatulence. Fats are less frequently at fault; but the presence of 
large unabsorbed masses in the intestine may be a sufficient cause of 
irritation. The actual pain in colic is partly from distention, but chiefly 
from muscular spasm. In some of the most severe cases of colic it is 
possible that the spasm may be accompanied by a slight transient in- 
tussusception. Colic may follow chilling the surface of the body. In 
these cases, also, muscular spasm appears to be the principal factor in 
causing the pain. The colicky period of infancy is chiefly the first 
three months; after this time the peculiar susceptibility gradually 
passes off. 

Symptoms. — These are in most cases so typical as to be easily recog- 
nized. They are always more severe in delicate and highly nervous chil- 
dren. In the severe attacks there is contraction of the features, a loud 
paroxysmal cry, subsiding for a few moments and then beginning with 
renewed intensity, drawing up the lower extremities, and in male in- 
fants contraction of the scrotum. With these symptoms the abdomen is 
usually found tense and hard. With the expulsion of gas, the symptoms 
usually subside at once, and the child falls asleep. In the most 
severe attacks there may be considerable prostration, cold extremities, 
and perspiration. When the symptoms are less severe there is only con- 
tinual fretfulness, and the child can not sleep. When colic is habitual 
there are very few hours in the twenty-four when the child seems to be 
entirely comfortable. In nursing infants there may at times be difficulty 
in distinguishing the cry of colic from that of hunger, as infants suffer- 
ing from colic will usually take food eagerly, and this is often followed 
by temporary relief. In colic, however, the pain soon returns, and often 
is more severe than before. The cry of colic is usually violent and 
paroxysmal; that of hunger is apt to be prolonged and continuous, and 
is not accompanied by the other symptoms mentioned as indicating ab- 
dominal pain. In older children the less frequent causes of colic men- 
tioned at the beginning of this article, especially appendicitis, should be 
borne in mind. 

Treatment — When colic is due to flatulence of the intestine, nothing 
given by the mouth lias much effect in relieving the symptoms. Cer- 
tainly food should not be given. The purpose of treatment during the 
attack is to assist the child to get rid of the gas; as this is usually in 
the colon, the mosl efficient means is by massage or enemata. At first 
an injection of four or live ounces of lukewarm water should be used. 
M' this is not successful, two ounces of colder water with half a teaspoon- 
I'ul of glycerin may be tried. This rarely fails to start peristalsis and 



CHRONIC CONSTIPATION 403 

expel the gas. In conjunction with these measures, dry heat should be 
applied to the abdomen by means of hot flannels or a hot-water bag. and 
the feet should be well warmed. The treatment between the attacks and 
the treatment of habitual colic should be directed toward the constipa- 
tion and the indigestion, upon which they depend. 



CHRONIC CONSTIPATION 

Constipation may be said to exist whenever the Stools are less fre- 
quent and firmer than normal. During the early months infants usually 
have two movements a day. Many, however, have only one; but if this 
is normal in character the child is not constipated. In other cases, 
although there are two and even three stools a day, they may all be 
small, dry, and hard, having all the characters of constipated stools, 
and the case should be treated accordingly. 

Etiology. — The causes of chronic constipation are many and far- 
reaching. It may be due to a diminution in the secretion of the intes- 
tinal glands or of the liver. The movements are then hard, dry, very 
light-colored, and are associated with much flatulence and other signs 
of intestinal indigestion. Yery often the principal factor in constipation 
is insufficient muscular contraction in the intestine. The fecal masses 
are then propelled so slowly and remain so long in the intestine that 
the fluid portion is absorbed, the residue becoming, in consequence, so 
dry and hard that it is difficult to expel. In other cases constipation 
is due to the fact that there is insufficient volume to the stools, as may 
be the case when the food leaves very little residue. Constipation may 
depend also upon local causes, as, for example, where an evacuation of 
the bowels is resisted on account of pain from fissure of the anus or from 
hemorrhoids. Although not the primary cause, this condition may be 
sufficient to keep up the constipation indefinitely. It may in rare cases 
be due to a congenital condition, such as narrowing or twisting of the 
large intestine at some point. Another rare cause seen especially in 
infancy is tonic spasm of the anal sphincter. The most important causes 
of constipation may be grouped under two heads: diet, ami conditions 
giving rise to muscular atony. 

Diet. — In breast-fed infants the trouble is usually low tola I solids in 
the milk. In those who are artificially fed it is mosl often because the 
sugar is too low, and sometimes because all the solid- arc too low. the 
stool lacking volume. In other cases the cause of constipation is indi 
tion, especially of fats, in still others lie use of sterilized milk. During 
the second and third years the cause may be too much cow's milk, par- 
ticularly that which has been boiled, or the use of an excessive amount 



404 DISEASES OF THE DIGESTIVE SYSTEM 

of starchy food. In older children lie cause may be an excess of milk 
and starchy food and a lack of green vegetables, coarse cereals, meat, 
fruit, and water. 

Muscular Atony. — The most common cause of muscular atony is 
habit ; in a large number of cases lack of proper training is the principal 
etiological factor. If the inclination to have a stool is regularly disre- 
garded it soon ceases to be felt. The ordinary irritation from fecal 
masses produces no response whatever. The longer such a condition 
continues the more obstinate does it become. This is an important 
factor in all cases. * Another cause of muscular atony is rickets. In this 
disease the muscular walls of the intestine suffer like the muscles of the 
extremities, and become incapable of doing their work. Again, any 
form of malnutrition in which there is feeble muscular tone may cause 
or aggravate constipation. It is often seen as a sequel to acute attacks 
of diarrheal diseases, particularly when these have been prolonged. 
Want of sufficient muscular exercise is a frequent cause. There are 
many children who rarely suffer from constipation in summer when 
they have plenty of outdoor exercise, who very often do so in winter 
when such exercise is wanting. A loss of muscular tone is not an infre- 
quent result of the prolonged and indiscriminate use of purgative drugs 
or enemata. 

Symptoms. — In most children no symptoms are present except the 
local ones, the general health being excellent and the nutrition in no way 
disturbed. In some, however, there are symptoms of greater or less 
severity, depending somewhat upon the cause of the constipation. 
There may be simply flatulence and colicky pains, or the irritation of the 
hardened fecal masses may produce a slight catarrhal inflammation 
of the sigmoid flexure and the rectum, so that mucus and sometimes 
traces of blood may be passed with the stool. Hemorrhoids may develop 
even in infancy, and frequently the constant straining leads to the pro- 
duction of hernia. In many cases there are from time to time nervous 
symptoms resulting apparently from the absorption of various toxic ma- 
terials from the intestine. There may be headache, dulness, fretfulness, 
disturbed sleep, and associated signs of intestinal indigestion. The 
urine often contains indican in excess, and there may be slight fever. 

Diagnosis.— This includes the discovery of the cause and the principal 
seat of the constipation. To arrive at the former the most careful and 
thorough investigation should be made of the child's diet and habits. It 
is desirable to determine whether the seat of trouble is the rectum, the 
colon, or the small intestine. If a suppository is almost immediately 
followed by a normal stool, one may be sure that the rectum only is at 
fault, and that it needs but a little extra stimulus to make it do its 
work. This is common in infants who are too young to make any 



CHRONIC CONSTIPATION 405 

voluntary efforts. In such cases there are no other symptoms present. 
In others, the white or gray stools, marked flatulence, offensive breath, 
and general irritability, leave no doubt of the fact that the trouble is 
due to indigestion. 

Treatment. — The successful treatment of chronic constipation in 
children is accomplished only by a careful study and regulation of the 
child's routine. In treatment, training, habits, diet and exercise play 
the most important, and specific remedies the least important part. 
Cure of the constipated habit is always difficult, and in most cases treat- 
ment must be continued for a long time. The cooperation of an in- 
telligent mother or nurse is absolutely indispensable. To establish the 
habit of regular stools should be the first step, for without it nothing can 
be done. This training should be begun in infancy. Even in young 
infants regular habits are formed without difficulty if the child is put 
upon the chamber or chair invariably at the same hour. When a local 
stimulus is required in addition, an oiled glass rod or a gluten supposi- 
tory may for a time be inserted. An older child must be taught to heed 
the first impulse to evacuate the bowel. Eegular habits can hardly be 
formed unless the same time each day is chosen for the movement. 
That to be preferred is soon after the morning meal, as taking food into 
the stomach starts a peristaltic wave which is continued throughout the 
intestine. This has been demonstrated by the X-ray to occur even in 
the colon. With older children breakfast should be early enough to allow 
ample time for this duty before the other engagements of the day; and 
nurses should be impressed with the importance of the early formation 
of proper habits on the part of their charges. It is a part of nursery 
discipline which should invariably be insisted upon. Stretching the 
sphincter under an anesthetic is sometimes of great benefit in infants, 
especially when tonic spasm is present. 

Food. — With nursing infants who get good breast-milk constipation 
is not common. When the milk is low in solids, constipation is frequent. 
In feeding cow's milk, constipation is overcome by giving the propor- 
tions of sugar, protein and fat which are best suited i<> the infant. It 
is rather more apt to occur with infants when, on accounl of digestive 
symptoms, modifications of whole milk or skimmed milk are giveD in- 
stead of those from top-milk. Bui constipation is also seen al times when 
I he fat is too high. The laxative effects of all sugars, but especially 
maltose, should be remembered (see Infant Feeding). Willi infants dur- 
ing the first year, chronic constipation may be largely prevented by 
proper milk modification. 

During the second year children who Suffer from constipation are 
usually benefited by reducing the amount of milk and giving more Bolid 
food. Especially valuable are the coarser cereal- thoroughly cooked and 



406 DISEASES OF THE DIGESTIVE SYSTEM 

purees of green vegetables, — peas, string beans, spinach or asparagus 
tips. Meat broths and beef juice are somewhat laxative on account of 
their extractives and salts. Fruits are valuable in all these cases; but 
only the juices should be given until a child is about fifteen months old. 
That of cooked fruit or almost any fresh fruit may be employed. After 
fifteen to eighteen months pulpy fruits may be given, but only after 
thorough cooking and straining,— apples, prunes, peaches, plums and 
pears, in moderate quantities ; but berries should be avoided. Eaw fruits 
should seldom be given to children under three years old, and after that 
age in moderate quantities only. 

For older children who are on a mixed diet the amount of starchy 
food should be moderate. Coarse cereals only should be given. Milk 
should be given rather sparingly; it is sometimes advisable to stop it 
altogether. All bread should be made from whole wheat or unbolted 
flour. Bran biscuits are also useful. Meat and broth may be allowed 
freely, also green vegetables and vegetable salads. All fruits allowed 
infants may be used, but in larger quantities, and in addition scraped 
raw apple. Of the dried fruits, dates, prunes and figs are permissible, 
but only after cooking. Fresh fruit is preferably given in the morn- 
ing, oranges being especially useful when taken on rising. A caution is 
necessary in the use of fruits and coarse foods for constipated children. 
It often happens that constipation is only one of the symptoms of a 
chronic intestinal indigestion, and such foods as those mentioned, while 
they may cause the bowels to move, frequently aggravate the primary 
condition. They produce abdominal pain, flatulence, and the discharge 
of mucus in the stools. The administration of some mild laxative even 
over a considerable period is often much less objectionable. 

The laxative effect of sugars may be utilized with older children, but 
they must be given with caution not to disturb digestion. Two or three 
teaspoonsfuls of honey may be given with the breakfast or supper. Mo- 
lasses may be used upon bread or may be added to cooked foods. 

Either hot or cold water, when taken an hour before breakfast, may 
be of considerable benefit to older children. The necessity of supplying 
sufficient fluids is apt to be overlooked, especially when milk is excluded 
from the diet. While a liberal amount of water is indispensable, there 
is do advantage in excessive water drinking. The sparkling waters, 
like Vichy or Apollinaris, are sometimes better than plain water. 

Massage, when properly employed, is useful in conjunction with other 
measures, but rarely succeeds alone. It should be given for five or ten 
minutes after retiring and just before rising. A proper amount of gen- 
eral muscular exercise is necessary and should be made a part of the 
treatment in every case. Special exercises for the development of the 
abdominal muscles when faithfully carried out are of particular benefit. 



CHRONIC CONSTIPATION 407 

Posture during the stool is of some importance; in certain cases a cure 
is effected simply by substituting a low seat on a nursery chair or closet 
for the high one previously used. 

Suppositories. — In many cases, particularly in young infants who 
are not old enough to initiate the muscular effort, a slight stimulus to 
the rectum is all that is required. The cone of oiled paper has a great 
reputation in domestic practice and is not objectionable. It may be of 
assistance in establishing a proper habit, Soap suppositories produce 
a more marked irritation; although their immediate effect is quite satis- 
factory, they should not be continuously used. Glycerin suppositories are 
even more objectionable. For occasional use they are convenient, but 
their frequent use, especially in infants, is likely to cause too much 
irritation. Gluten suppositories produce less irritation and are conse- 
quently slower in their effect, but they have not the same disadvantages. 
Suppositories are useful only when the trouble is in the rectum. 

Enemata. — Water enemata should not be used regularly for the relief 
of chronic constipation. For immediate relief they are often necessary. 
The injection of one or two drams of glycerin in a few ounces of water 
is one of the most efficient means of moving the bowels at our command. 
Cases of fecal impaction are rarely met with in children. They are 
to be managed as in adults, by repeated injections of soap and warm 
water or of ox-gal], and sometimes by mechanical removal. An injection 
of an ounce or two of sweet oil may facilitate the passage of very bard 
and dry stools, and a regular nightly repetition of this, or a somewhat 
larger amount, for several weeks will sometimes break up a constipated 
habit. 

Medicinal Treatment. — This is the least important part of the man- 
agement of chronic constipation. The most valuable laxatives are prepa- 
rations of cascara, nux vomica, belladonna, hyoscyamus and phenol phtha- 
lein. Though in most obstinate cases they are necessary, they should he 
used as little as possible and the dose gradually diminished. With mosi 
drugs the prolonged use of small doses is better than the occasional use 
of large ones. Cascara may be used either in the form of the elixir (dose 
from one-half to one dram), or the fluid extract, from one to live drops. 
Rhubarb, either in the form of the syrup or the mixture of rhubarb 
and soda, may he given occasionally, bul it is not adapted to continuous 
use. Of salines, magnesia and phosphate of soda arc best for continuous 
use in infants. All the preparations of malt possess slight laxative 
properties, and are useful in conjunction with dietetic and other medic- 
inal means; any of the extracts of malt may he employed. Olive oil 
is often of assistance in the treatment of the constipation both of infants 
and older children. To the former the usual dose is one teaspoonful 
three times a day; to the latter, two or three times this amount should 



408 DISEASES OF THE DIGESTIVE SYSTEM 

be given. Mineral oil (petrolatum liquidum) is a valuable remedy, but 
is applicable only to older children, to whom from half an ounce to one 
and a half ounces daily must be given. It should be administered on 
an empty stomach, or it is likely to disturb digestion. As it is not 
absorbed, its action is purely local. The latest investigations indicate 
that the Eussian oil has no advantages over American products, pro- 
vided the latter have been suitably refined. Agar-agar has a beneficial 
action by rendering the fecal mass softer and more easily expelled. It 
should usually be combined with some other laxative such as phenolphtha- 
lein, cascara or rhubarb. It should be broken up into fine fragments 
and may be mixed with the cereal, with thick soup or simply with 
water. The dose is two or four teaspoonfuls daily. 



HYPERTROPHY AND DILATATION OF THE COLON 

(Hirschsprung's Disease) 

Hirschsprung's disease is characterized by a great increase in the 
diameter of the colon and in the thickness of its wall. It was originally 
believed to be an idiopathic condition for which no sufficient anatomical 
cause could be found. Hence it has been known as congenital or 
"idiopathic" dilatation of the colon. Within recent years, however, it 
has become increasingly clear that in the majority of cases there is an 
obstruction to the passage of the intestinal contents through the large 
intestine, although when the intestines are removed and laid open, no 
evidence of obstruction can be found. The dilatation and hypertrophy 
are greatest in the sigmoid, and in about one third of the cases, this 
alone is affected. In the majority of instances, however, all of the 
colon is involved; very rarely only the colon above the beginning of 
ths sigmoid is affected. The degree which the dilatation and hypertrophy 
may reach is enormous. The colon may fill the greater part of the 
much dilated abdominal cavity. There may be pressure upon, with a 
certain amount of atrophy of, the rest of the abdominal contents and 
the capacity of the thorax may even be encroached upon, the diaphragm 
being displaced upward to a marked extent. The inspissated contents 
of the colon may be many pounds in weight. The hypertrophy is chiefly 
due to an increase in the circular muscular fibers of the affected portion 
of the large intestine. The mucous membrane may be normal or there 
may be large and oftentimes deep ulcers which usually do not extend 
beyond the muscular coat but may involve this and even lead to perfora- 
tion of the intestines with the consequent lesions of peritonitis. 

Al operation and at autopsy, when attention is especially directed 



HYPERTROPHY AND DILATATION OF THE COLON 409 

to the obstruction, it is found that this is usually the result of an 
abnormally long sigmoid and mesosigmoid which allows the lower por- 
tion of the sigmoid flexure to fall forward and downward, thus pro- 
ducing an angulation at its junction with the rectum. With the forma- 
tion of this angle, the tendency is for the obstruction to increase and as 
the result of the effort of the portion of the large intestine proximal to 
it to overcome this obstruction, hypertrophy and dilatation take place. 
This is the factor which, in a majority of the more recently studied 
cases, has evidently been the determining one. In a small number of 
instances, hypertrophy of the transverse striations of the rectum have 
been found sufficiently marked to cause some obstruction. Other causes, 
such as spasm of the intestine, deficient innervation and congenital 
dilatation and hypertrophy, have been used to explain the condition 
when no anatomical basis for it has been found but Ihey lack any 
convincing proof. 

The symptoms may appear soon after birth or may be delayed 
months or even years, depending upon the severity of the mechanical 
disturbance. The most striking symptom is the increase in the size of 
the abdomen; this may develop rapidly or slowly. The distention may 
reach an extraordinary extent, the abdomen being almost spherical. 
The greatest circumference is usually just above the navel. The dis- 
tention is chiefly due to gas, although there may be a sufficient accumu- 
lation of fecal material to cause circumscribed dulness and marked 
resistance over the colon. 

The constipation is more marked than is seen in any other condition. 
Days, even weeks may pass by without an evacuation from the bowels. 
The feces are then usually dry, dark brown or greenish and very foul. 
Occasionally mucus and blood are passed and in the late stages of the 
disease there may even be diarrhea, the result of ulceration. Marked 
peristaltic waves are almost always seen; they are usually in the lower 
part of the abdomen and on the right as well as on the left side. Pres- 
sure upon the abdomen is seldom painful and only to a slighl exteni 
unless some complication such as peritonitis is present. By rectal 
examination an obstruction to the finger is frequently encountered. 
This may be at times overcome and not infrequently a rectal tube may 
be passed beyond it. It is then frequently found thai water may be 
injected, which is only expelled after a considerable length of time 
The urine is usually normal except for the presence of indican in large 
amount. 

Attacks of vomiting from time to time are not unusual, hut in gen- 
eral the digestion is good. The condition may last for many war- ami 
may not be incompatible with normal growth. Very occasionally .spon- 
taneous recovery apparently occurs. Usually the condition becomes gradu- 



410 DISEASES OF THE DIGESTIVE SYSTEM 

ally worse, the nutrition fails, there may be attacks of diarrhea with 
fever, or death may be due to some intercurrent infection, frequently 
of the lungs. Perforative peritonitis is an occasional fatal complication. 

The two conditions most likely to be confounded with Hirschsprung's 
disease are tuberculous peritonitis and chronic intestinal indigestion. 
Chronic intestinal indigestion is a relatively common condition. It 
occurs frequently as the result of some frank intestinal disease, usually 
between the first and second year. There are frequent attacks of 
diarrhea alternating with constipation which is never so marked as in 
Hirschsprung's disease. The distention is of the small and large in- 
testine as well and is seldom accompanied by peristaltic waves which 
are never very marked. Chronic intestinal indigestion is seldom seen at 
the early age at which Hirschsprung's disease is often found and the 
general condition of the child is always bad, while with Hirschsprung's 
disease the general health may be excellent for a long time. 

Tuberculous peritonitis is characterized by a more rapid onset, by 
the presence, oftentimes, of fluid in the abdominal cavity and of ab- 
dominal tumors, by evidence of tuberculosis elsewhere and by the pres- 
ence of the von Pirquet reaction. Compared with the frequency of these 
two diseases, Hirschsprung's disease is a very rare condition. 

The treatment of Hirschsprung's disease is palliative so long as 
the general health remains good and without evidence of increase in the 
distention. It consists in careful feeding, occasional enemata and by 
the attempt, which is sometimes successful, of overcoming the angulation 
of the intestine by preventing fecal retention. In case the symptoms 
become more severe and the general health undermined, it is evident 
that obstruction is becoming more marked and operative procedure 
should be considered. Many different operations have been suggested; 
the only one which can be successful is one that involves the entire 
removal of the obstruction wherever this may be. In the past the results 
have not been very satisfactory, but with increasing knowledge and 
experience, operative treatment has become more successful. 



INTUSSUSCEPTION 

[ntussusceptiorj consists in the invagination of one portion of the 
intestine into another. It occurs most frequently in infancy, being at 
I his age the most common cause of acute intestinal obstruction. The 
accident is not a common one, but the life of the patient generally de- 
pends upon its prompt recognition. 

Varieties. — Usually the upper part of the intestine is invaginated into 
the lower, although the reverse is occasionally seen. Intussusceptions 



INTUSSUSCEPTION 4 1 1 

may occur at any point in the intestinal tract. Those of the small intes- 
tine are called enteric; those of the colon, colic; and those occurring at 
the ileocecal valve, ileocecal (Fig. 44). Of 90 cases under ten years 
of age, in which the variety was determined by autopsy or operation. 75 
were ileocecal, 9 colic, and 6 enteric. In the ileocecal form a few- 
inches of the ileum pass through the ileocecal valve, and then invagina- 
tion of the colon occurs. Cases in which the ileum passes through the 




Fig. 44. — Ileocecal Intussusception. A specimen removed from a child in the New 

York Infant Asylum. 



valve, but without invagination of the colon, are sometimes classed sepa- 
rately as an ileocolic variety. 

Intussusceptions of the dying, as they have been called, arc mel with 
in about eight per cent of all autopsies made upon infants; they are qoI 
often found in children over two years of age. They are descending, 
enteric, easily reducible, and multiple — usually from eighl to twelve 
invaginations being present. They are more frequentlj in the jejunum 
than in the ileum. They usually involve bul two or three inches of 
the intestine, but may include ten or twelve inches. The} are found 
in autopsies upon patients dying of all varieties of disease, ami are 



412 DISEASES OF THE DIGESTIVE SYSTEM 

probably produced in the death agony. Such intussusceptions are with- 
out symptoms, and are of no clinical importance. 

Etiology. — Of 358 collected cases under ten years, the following are 
the ages reported : under four months, 28 cases ; from four to six months, 
113; seven to nine months, 71; ten to twelve months, 18; one to two 
years, 32 ; two to ten years, 96. Three-fourths of the cases which occur 
in childhood are, therefore, in the first two years, and one-half of them 
between the fourth and ninth months. The greater frequency in infancy 
is attributed to the thinness of the intestinal walls, the greater mobility 
of the cecum and ascending colon, and the presence of other intestinal 
derangements at this age. 

Males are more often affected than females. Of 268 cases in which 
the sex was mentioned, there were 174 males and 94 females. For this 
fact there is no explanation. The exciting causes of an attack are ex- 
tremely obscure. The great majority of cases occur in children who are 
apparently in perfect health. Some previous intestinal disorder was 
present in about three per cent of the cases we have collected — diarrhea, 
dysentery, colic, chronic indigestion, and constipation, all being men- 
tioned. In four cases the intussusception was ascribed to injury of the 
abdomen. 

Lesions. — Nothnagel's animal experiments have shown conclusively 
that intussusceptions are formed by the irregular action of the muscular 
walls of the intestine. They can be produced or released at will by vary- 
ing the application of the electrical current. In the artificial intussus- 
ception there is first a contraction of a certain part of the intestine, and 
if this ceases abruptly the normal gut below this point turns upward and 
folds over upon the contracted portion, thus forming a minute intus- 

r\ susception (Fig. 45, A). When 

once begun, the intussusception in- 

^ creases solely at the expense of the 

FlG - 45 ' A - external layer (Fig. 45, B). Thus, 



Fig. 45, B. — Mechanism of Intussusception. (Treves.) 

while the apex of the tumor D remains unchanged, the part of the 
sheath at A passes to B and then to C, so that the lower part of the 
intestine is drawn over the upper, rather than the upper crowded into 
the lower. The mechanism of the invagination was apparently the same 
when a part of the intestine was first paralyzed by crushing, as in the 
case in which a spasm of the intestine was first produced. 

There is little doubt that pathological intussusceptions are produced 



INTUSSUSCEPTION 413 

in the same way as in these experiments. As the invagination takes 
place, the mesentery is drawn in with the bowel, and always lies between 
the sheath and the inner layer. To allow intussusception to occur, the 
mesentery must be unduly long, stretched, or lacerated. Its attachment 
to the spine causes the intussusception to describe an arc of a circle, the 
concavity of which is always toward the spine. It also causes a puckering 
of the tumor. Invagination does not necessarily produce either ob- 
struction or strangulation, but usually both are present, and are the 
chief causes of the symptoms. Traction upon the mesentery leads to 
obstruction in its vessels, causing congestion, edema, hemorrhages, and 
even gangrene. Obstruction is chiefly due to swelling. It may be due 
to dragging of the mesentery, which brings the apex of the tumor against 
the side of the gut, or to bending of the intussusception. Intussusception 
is usually of all the coats of the intestine. We have, however, seen one, 
the exact nature of which was determined by operation, in which only 
the mucosa and submucosa were involved. The invagination was at the 
ileocecal valve. The symptoms were characteristic except for the ab- 
sence of tumor. 

The great cause of irreducibility in the first two or three days is 
swelling. We have several times seen at autopsy or operation an intus- 
susception easily reduced, except the last two or three inches of the 
cecum or ileum, which was swollen to the thickness of from a fourth 
to half an inch. Adhesions may prevent reduction, but rarely before the 
fourth day; they are often absent as late as the sixth or seventh day. 
They are usually between the internal and middle layers of the intus- 
susceptum, and are due to local peritonitis. In chronic cases, however, 
they form the principal obstacle to reduction. Other causes of irreduci- 
bility are twisting of the tumor and pinching of the prolapsed intestine, 
especially the ileum by the ileocecal valve. 

Gangrene and sloughing of the gangrenous portion of the intestine 
occur much more often in acute than in chronic cases. Portions of 
intestine were passed per anum in 24 of 362 cases under ten years, or 
about six per cent; but only two of these were in infants. Toward the 
end of the second week is the time when the separation of the sloughs is 
to be looked for. The amount of intestine discharged varies from a few 
inches to several feet. Two cases are on record in which the entire colon 
was passed, the patients recovering, but dying several months Inter from 
other causes. At the autopsies the ileum was found attached t<> the lower 
part of the rectum just above the anus. In acute cases gangrene occurs 
about the upper end of the tumor, and the inn-tine usually comes away 
in one large mass. In chronic cases shreds of intestine may be dis- 
charged for several weeks. 

Symptoms. — The clinical picture of a case of inl »tion ifl a 

15 



414 DISEASES OF THE DIGESTIVE SYSTEM 

striking one, and when acute the symptoms are so uniform that, once 
seen, it can scarcely be overlooked a second time. The patient, usually 
between six and twelve months of age, is taken suddenly ill with severe 
pain and vomiting; the pain recurs paroxysmally every few minutes, 
and the vomiting is first of the contents of the stomach, and after- 
ward bilious. There may be one or two loose fecal stools, then only 
blood or blood and mucus are passed without any admixture of feces. 
The general symptoms are those of great prostration, or even collapse — 
pallor, feeble pulse, apathy, and normal or subnormal temperature. The 
abdomen is relaxed. A tumor is usually present in the epigastrium or 
the left iliac fossa, or it may be. felt per rectum. Later there is tym- 
panites; the vomiting and pain continue; there is a steady increase in the 
prostration, and toward the end a rapidly rising temperature which may 
reach 105° or 106° F. before death occurs from collapse. If the symp- 
toms continue longer the signs of peritonitis are added. In subacute 
cases the onset is less abrupt, and pain, vomiting, and constipation less 
constant and less severe; but the same symptoms are present. In chronic 
cases the onset is with vague, indefinite intestinal symptoms; pain, vom- 
iting and bloody discharges are usually wanting; there is progressive 
wasting and more or less diarrhea, but only the presence of the tumor 
leads to the recognition of the condition. 

Onset. — Of 193 cases under ten years in which data upon this point 
could be obtained, the onset was sudden in 181 and gradual in 12 cases. 
By far the most frequent symptoms of onset are pain and vomiting. In 
a smaller number of cases the initial symptom is diarrhea or a dis- 
charge of blood and mucus. 

Pain. — This is rarely continuous, but is intermittent, recurring in 
paroxysms like those of ordinary colic, but of great severity. Few pains 
in infancy are to be compared with it. The child sometimes shrieks so as 
to be heard all over the house. Pain is a prominent symptom in over 
| three-fourths of the cases, and is very rarely absent. It is generally more 
.marked for the first two days, but may continue throughout the attack. 
In a few cases the pain is localized, being usually referred to the region 
of the umbilicus. 

Vomiting is more marked at the onset, but may continue throughout 
the attack. Like the pain, it is more frequent in the acute cases. It is 
due to intestinal obstruction. Vomiting is present in fully four-fifths 
of all cases. Usually it is persistent and often projectile. If food is 
given, vomiting often occurs as soon as it reaches the stomach. Stercora- 
ceous vomiting occurs in about fifteen per cent of the cases in children 
m under ten years, but is not common in infancy. It is rarely present 
before the third or fourth day. Although a bad sign, it is not by any 
means a fatal one, as nearly one-half the cases in which it has been noted 



INTUSSUSCEPTION 



415 



have recovered; it is to be regarded as indicating complete intestinal 
obstruction rather than strangulation. 

Tumor. — This is one of the most important symptoms for diagnosis 
because of its frequency and its peculiar character. It is present early in 
the disease, often in a few hours after the initial symptoms. The follow- 
ing table shows the frequency with which a tumor was present in the 
different varieties, and the position which it occupied in each. The 
anatomical variety was determined either by autopsy or operation. 

The Relation between the Tumor and the Different Varieties of Intussus- 
ception in 188 Cases under Ten Years. 



Seat of Tumor. 






Seat of Intussusception 






Ileocecal. 


Ileocolic. 


Colic. 


Enteric. 


Not Stated. 


Total. 


Region of cecum 


1 

3 

3 

4 

25 

9 

i 


3 
1 


1 

7 
1 


1 

1 
1 


7 

12 
13 
18 

8 
28 
12 

'2 


11 


" " ascending colon 
" " transverse colon 
" " descending colon 
" " sigmoid flexure. 
Rectum 


13 
16 
21 
13 
61 


Protruding from anus .... 
Umbilical region 


22 
1 


Movable 


3 


Site unknown 


1 






Total 


46 
10 


4 

2 


9 


3 
1 


100 
13 


162 


No tumor felt 


26 







Tumor was thus made out during life in eighty-six per cent of the 
cases; and in the great majority of these it was discovered at the first 
careful examination. 

It will be noted that in nearly half of the cases the tumor was either 
felt in the rectum or protruded from the anus, and that in over two- 
thirds it had advanced as far as the descending colon or beyond. The 
tumor may reach the rectum in a surprisingly short time even when 
the invagination begins at the ileocecal valve. In one of out cases it 
was felt in the rectum in less than twelve hours from the onset. The 
usual description, "sausage-shaped/' is accurate when the invagination 
is large, the tumor then being from four to six inches long and about 
an inch and a half in diameter. It is often curved. 

During manipulation, or during an attack <>!' pain, the tumor may 
become more prominent and may be distinctly erectile. To the touch 
the rectal tumor closely resem b les the os uteri, the central opening being 
the apex of the intussusception. When protruding from the body, the 
tumor is rarely more than two inches long- It is osuall) of a deep- 



416 DISEASES OF THE DIGESTIVE SYSTEM 

purplish color, and may be gangrenous. It has been mistaken for 
prolapsus ani, polypus, and even hemorrhoids. 

Condition of the Bowels. — Bloody stools are a very constant symp- 
tom. Of 186 cases under ten years in which the condition of the bowels 
was noted, blood in the stools was present in seventy-six per cent. There 
are very often two or three thin, diarrheal movements, and then only 
blood and mucus are passed with no trace of feces and with no fecal 
odor. The amount of blood varies from a quantity sufficient to stain 
the mucus, to an ounce of semi-fluid blood. It rarely occurs without 
some mucus. Such discharges frequently follow attacks of severe colicky 
pain, and may occur several times in an hour. They may continue, or 
after a day or two they may be succeeded by absolute stoppage. Diar- 
rhea throughout the attack is rare in children, particularly so in in- 
fants. It belongs generally to chronic cases. Constipation is complete 
in most of the acute cases, neither gas nor feces being passed — a fact 
which the discharge of blood and mucus may lead one to overlook. 

Tenesmus is very common if the tumor is rectal. Eelaxation of the 
sphincter is met with in a considerable proportion of the cases when the 
tumor is in the sigmoid flexure, or rectum. 

During the first twenty-four or forty-eight hours the abdominal walls 
are soft and relaxed, and may even be retracted. Usually there is then 
little resistance to abdominal palpation. After the second or third day 
there is usually tympanites; but this does not necessarily mean that 
peritonitis exists. Localized tenderness is a symptom of some impor- 
tance when a tumor is absent. Scanty urine has been noted in a few 
cases, but is of no special value in showing the seat of obstruction. 

In the acute cases the general symptoms are very striking. They are 
the ordinary ones of severe shock — marked prostration, pallor with an 
anxious expression of the face, general muscular relaxation, cold extrem- 
ities, cold perspiration, and often a subnormal temperature. Early there 
is marked restlessness, and even convulsions may occur. Later there is 
apathy, dulness, even semi-stupor. The temperature during the first 
twenty-four hours is usually not elevated, and is frequently subnormal. 
Toward the close of the disease it rises rapidly to 103°, 104° F., or even 
higher, quite independently of peritonitis. A rapidly rising temperature 
is always a bad symptom, and usually betokens death within twenty- 
four hours. Wasting is seen in the chronic cases, and may be quite 
rapid. 

Course, Duration, and Termination. — Of 198 cases under ten years, 
155 were classed as acute, lasting less than seven days; 33 as subacute, 
lasting from one to four weeks ; 10 were chronic, lasting over four weeks. 
Nearly all the cases occurring in infancy are acute. 

Spontaneous reduction is, without doubt, possible in intussusception. 



INTUSSUSCEPTION 417 

Treves and others are of the opinion that this happens much more fre- 
quently than is generally supposed, and that many cases of severe colic 
are really cases of slight intussusception. There are seen in both con- 
ditions the tendency to vomit, the paroxysmal pain, the constitutional 
depression, and often the sudden cessation of the symptoms, especially 
under the influence of opium ; but to make a positive diagnosis of invagi- 
nation in such cases is impossible. Intussusception may be cured spon- 
taneously by sloughing of the invaginated part, the continuity of the 
intestine being preserved by adhesions. Such a result is rare at all ages, 
and is almost never seen in infancy. 

The most frequent cause of death in acute cases is shock. Peritonitis 
is not found at autopsy or operation so often as might be expected. In 
fifty-eight autopsies, it was seen but twenty times, and in seven of these 
it was limited to the intussusception. In but seven cases was there 
perforation. 

Diagnosis. — This usually presents no difficulty in acute cases provided 
the physician has the condition in mind. The great majority of such 
cases present nearly all the classical symptoms, viz., sudden onset, recur- 
ring colicky pains, frequent vomiting, bloody and mucous stools without 
fecal matter, general prostration or collapse, and low temperature. The 
records show that the most common error is to regard the case for the 
first few days as one of gastro-enteritis or ileocolitis, the physician's 
attention being engrossed by the vomiting and bloody stools. Given 
the other usual symptoms, the presence of the characteristic tumor is 
conclusive evidence of intussusception. Unless the patient is very much 
relaxed, a satisfactory examination is possible only under full anesthesia. 
In any case of acute intestinal obstruction in infants, intussusception 
should first be considered. We once saw in a young infant with strangu- 
lated hernia nearly every symptom of intussusception except the ab- 
dominal tumor; in another infant with an inflamed Meckel's diver- 
ticulum there was vomiting, bloody and mucous stools and an elon- 
gated tumor in the hypogastric region. Cases of chronic intussuscep- 
tion present no diagnostic symptoms except the tumor. Tn both acute 
and chronic cases the rectal examination is most important for diag- 
nosis, and often settles the question at once. 

Prognosis. — The prognosis of intussusception depends upon the ;iL r <' 
of the patient, upon the variety of the disease — whether acute, sub- 
acute, or chronic — and upon the time when proper treatment is begun. 

There were collected by Pilz in 1870, 94 cases under one year, the 
mortality being 84 per cent. Of 135 cases of the same age reported 
between 1870 and 1891 the mortality was 59 per cent. Results in older 
children were somewhat more favorable. Formerly recovery was rare, 
except in cases with sloughing; but with earlier diagnosis and a better 



418 DISEASES OF THE DIGESTIVE SYSTEM 

understanding of the proper methods of treatment, the mortality 
been very mnch reduced. Combining the figures of Pilz with our own, 
there are 362 cases with 231 deaths, or 63.5 per cent. 

Gibson (New York) has collected reports of 187 operations for intus- 
susception, with a general mortality of 51 per cent; in 126 cases, in 
which the tumor was reducible, it was but 36 per cent; in 61, in which 
it was irreducible or gangrenous, it was 80 per cent. The table following 
gives the mortality in relation to time of operation : 



Time of Operation. 



Mortality, 
Per cent. 



First day . 
Second " . 
Third " . 
Fourth " . 
Fifth « . 
Sixth " . 



37 
39 
61 
67 
73 
75 



After the second day the chances of success are greatly reduced. 

Treatment. — The diagnosis of acute intussusception once made, lapa- 
rotomy should immediately be performed without an hour's unnecessary 
delay. The results following inflation of the intestine with air and' 
injection with water are too uncertain to be depended upon. 

Operation should be looked upon as a measure which, if employed 
reasonably early, offers a good prospect of success. All statistics show 
that the result depends more upon the time when the operation is done 
than upon any other single factor. With earlier diagnosis and more 
prompt resort to operation, the mortality from acute intussusception has, 
during the past fifteen years, been steadily falling. In chronic cases, 
also, laparotomy offers altogether the best chance of success. 



CHAPTEE IX 
DISEASES OF THE INTESTINES.— (Continued) 

APPENDICITIS 

Appendicitis is met with at all ages, and is not especially a disease 
of children. When it attacks those over ten or twelve years of age it 
docs not differ greatly from the types observed in adults. All that will 
be attempted in this chapter will be a consideration of the peculiarities 



APPENDICITIS 419 

of the disease as it is seen in children, particularly young children. For 
a fuller discussion of the disease as a whole the reader is referred to 
works on general medicine and surgery. 

Etiology. — Of 1,000 cases of appendicitis personally observed by 
McCosh, 85 occurred in children between the ages of ten and fifteen 
years; 51 between the ages of five and ten years, and only 17 under five 
years; of these but 4 were under two years. Churchman's figures from 
the Johns Hopkins' Hospital, in a total of 1,223 cases, give only 9 cases 
under five years, and 50 between five and ten years. In infancy and 
early childhood appendicitis is, therefore, a relatively rare disease. The 
youngest case that has come under our observation was in an infant of 
ten weeks. Operation was done and recovery followed. Appendicitis 
in young infants has been reported by Goyen (six weeks), Shaw (seven 
weeks), Demme (seven weeks) and Savage (nine weeks). The pre- 
dominance of the male sex holds true even in childhood. Of 101 cases 
under fifteen years, 72 were males and 29 were females. 

Eegarding the exciting cause of an attack but little is yet definitely 
known. In only a very small proportion of the cases is a foreign 
body discovered in the appendix. In one of ours a pin was found. 
and a number of similar cases are on record. There is, however, often 
a fecal concretion which is moulded into the shape of a foreign body, 
and formerly was often regarded as such. This probably has some 
relation to the attack by causing disturbances of circulation and in- 
creasing the chances of infection. Still and others have called attention 
to the frequent occurrence of pin worms in the appendices of young chil- 
dren. There is abundant reason for believing that these may at times 
be the exciting cause of an attack. The bacteria most frequently found 
in abscesses from appendicitis are streptococci, usually associated with 
colon bacilli. 

Lesions. — All the common varieties of acute appendicitis, — the catar- 
rhal, suppurative, and gangrenous, — are met with in children : and. much 
less frequently, the chronic form. The lesions preseni few peculiarities 
in early life except that, owing, possibly, to the relation of the appendix 
to the omentum, perforative inflammations are less likely to be circum- 
scribed by inflammatory products and much more likely to result in a 
general peritonitis than in adults. Whether or not this be the eorred 
explanation, it is certainly true that general peritonitis is a much more 
common sequel than in adults. Another point of some importance is 
the fact that in early life the appendix is rather more frequently found 
out of the usual position. The inflammation excited by pin wormi is 
usually a superficial one; perforation and abscess formation are almost 
unknown when they are the cause. 

Symptoms. — In many of the cases the familiar symptoms of a] 



420 DISEASES OF THE DIGESTIVE SYSTEM 

dicitis — vomiting, localized pain and tenderness, muscular rigidity, ab- 
dominal distention, and fever — are all present, and the diagnosis is easy. 
But in perhaps the larger number the disease is irregular in its onset, 
insidious in its course, and presents at times great difficulties in diagnosis. 
This is particularly true of appendicitis in children under five years. 
Vomiting is probably the most constant symptom; it is seldom absent, 
and usually persistent. If accompanied by pain and constipation, ap- 
pendicitis should at once be thought of. Pain, though usually present, is 
often indefinite ; it is generally hard to localize and difficult to interpret. 
It may be referred now to one and now to another part of the abdomen. 
Often the only evidence of pain is restlessness, irritability, and, in in- 
fants, frequent crying. Tenderness is even more difficult to elicit than 
pain. Young children, especially if nervous and sensitive, shrink from 
any touch, and the results of abdominal palpation may be most unreli- 
able. In others of a different temperament positive information may be 
obtained. In any child under three years, it is almost impossible to 
make out localized tenderness. The same is true of muscular rigidity. 
Only with the greatest amount of tact and by diverting the patient, 
can any information be derived from this part of the examination. 
Tenderness and muscular rigidity are sometimes shown by the child's 
disinclination to move either the trunk or lower extremities and by evi- 
dences of pain when he is moved by mother or nurse. When associated 
with vomiting, fever, and constipation, such symptoms are always 
suggestive. 

Constipation is usually present, but by no means so regularly as in 
adults. Diarrhea is not at all uncommon, and, when associated with 
vomiting, tends to divert attention from the appendix to an ordinary 
gastro-intestinal attack. Abdominal distention, when present, is of much 
importance, taken with other symptoms. Fever is rather more apt to 
be high than in adults. But there are many exceptions, and, on the 
whole, the temperature is a very untrustworthy guide either to diag- 
nosis or prognosis. The leucocyte count is of much assistance in diagno- 
sis, at least in suppurative forms of appendicitis. A leucocytosis of at 
least 10,000 to 20,000 is usually present, with a polymorphonuclear per- 
centage over 75. Some special symptoms may be seen in appendicitis 
which are quite misleading. We have on several occasions seen frequent 
micturition and other marked manifestations of vesical irritation, ow- 
ing to the position of the appendix behind the bladder. Pain just before 
and during defecation is occasionally a striking symptom especially with 
infants. The rigidity of the thigh flexors seen in cases of appendicitis, 
which comes on with subacute symptoms, may give rise to lameness 
strongly suggestive of disease at the hip. 

Course of the Disease. — A certain number of cases begin with definite 



APPENDICITIS 421 

symptoms — pain, vomiting, fever, and constipation — and continue with 
slowly or rapidly advancing symptoms to increasing prostration, con- 
tinued vomiting, constipation, rapid pulse, abdominal distention, rigid- 
ity, higher temperature, and death by general peritonitis at the end 
of five or seven days' illness. Others, with a similar onset, show a 
gradual abatement of all acute symptoms after a few days, and recovery 
at the end of ten days or two weeks, followed, perhaps, by another at- 
tack after a few months. These types are seen in children as in adults. 
But others are quite common. A child may be taken ill, sometimes 
abruptly, sometimes more gradually, with vomiting, which is repeated 
several times in a single day, afterward only occasionally. There is 
some pain; it is not very definite and not localized. The prostration is 
only moderate, the temperature not over 100° or 100.5° F. The exami- 
nation shows little. Tenderness can not be definitely made out; the 
child is irritable, fretful, wishes to be left alone, and resists all efforts at 
abdominal palpation. The bowels are constipated, or they may be at first 
loose and afterward constipated. The child does not seem very sick. 
The attack is probably regarded as an ordinary one of acute indigestion. 
But things do not improve as they ought. The pulse becomes more 
rapid, the prostration greater, and the child begins to look seriously ill, 
though the temperature has not risen. The abdominal distention is now 
considerable and tenderness undoubted. An operation is decided on, and 
there is found a gangrenous appendix and a diffuse general peritonitis. 
Sometimes the grave symptoms develop with great rapidity in the course 
of a few hours, when previous symptoms had all been mild ; sometimes 
so insidiously that the transition is almost imperceptible. 

Prognosis. — The prognosis in young children is not good; of 132 
collected cases in infants and very young children the mortality was 38 
per cent. But in those over seven years old the outlook is rather better 
than in adults. The results depend much upon early diagnosis and 
proper treatment. General peritonitis, it is generally agreed, occurs 
much oftener in children than in adults; it is the cause of death in about 
80 per cent of the cases. Of 43 fatal cases, nearly all of them from 
general peritonitis, only 6 died during the first three days, 1!» from the 
fourth to the seventh day, 13 in the second week, and 5 in the third 
week. If general peritonitis occurs, the chances of recovery after opera- 
tion are, however, usually better with children than with adults. 

Diagnosis. — The diagnostic symptoms <»f appendicitis are ;i Budden 
onset with vomiting, sharp pain in the abdomen, and persistenl acute 
localized tenderness in the right iliac fossa. Rigidity of any or all of 
the abdominal muscles is also significant. Constipation is more fre- 
quent than diarrhea, though the latter is n.»i rare. There is almbsl 
invariably some elevation of temperature, hut not often high fever. 



4>2 DISEASES OF THE DIGESTIVE SYSTEM 

Appendicitis may be confounded with colic, indigestion, and in 
infants with intussusception; in older children with abscesses due to 
psoitis. Colic is distinguished by the absence of localized tenderness and 
fever, by its short duration, and by the fact that the pain is generally 
less intense. Severe colic with fever in children over three years old 
should, however, always be regarded with suspicion. From acute indi- 
gestion the diagnosis of appendicitis is difficult at the onset, and it may 
be impossible for twenty-four hours. However, the pain of indigestion 
is rarely so severe, while the fever is usually higher. It should be re- 
membered that the pain in appendicitis is not always localized, nor is 
the tumor always in the right iliac fossa. The presence of pain, vomit- 
ing, and localized tenderness, and the greater severity of the constitu- 
tional symptoms, indicate appendicitis. We have several times known 
the pleurisy accompanying pneumonia at the right base to be mistaken 
for appendicitis. With this there may be vomiting, severe localized pain, 
and sometimes also localized tenderness. Cyclic vomiting is distin- 
guished by the history of previous attacks, the greater frequency with 
which the vomiting occurs, its abrupt cessation after twenty-four to 
seventy-two hours, the sunken abdomen, and the absence of pain, tender- 
ness, and rigidity. The presence of early acetonuria is also charac- 
teristic. Intussusception, with its pain, colic, and vomiting, may sug- 
gest appendicitis, but is rare, except in infants; fever is absent early 
in the disease, and a tumor is usually present. Acute or subacute 
suppuration in the right iliac fossa is almost invariably due to 
appendicitis. 

The leucocyte count may be of considerable assistance in differentiat- 
ing appendicitis from colic, cyclic vomiting, ileocolitis, and intussus- 
ception. It should, however, be remembered that in some of the gravest 
cases the leucocytosis may be slight or there may be none at all. On 
the whole, while the presence of marked leucocytosis — i. e., above 20,000 
— may be of considerable assistance in the diagnosis, no inference can 
be drawn from a normal count or a slight leucocytosis if the child is 
greatly prostrated. Whenever, in children over two years old, there are 
symptoms pointing to acute peritonitis, no matter what their combina- 
tion or variety, appendicitis should always be suspected. 

Treatment. — Absolute rest in bed can not be too strongly insisted 
upon whenever appendicitis is suspected, no matter how mild the attack" 
may appear. As a local application, the ice-bag is to be preferred. 
Opium should not be given. It does harm by obscuring important 
symptoms and increasing constipation. The colon should be kept empty 
by the daily use of enemata. After a thorough clearing of the bowels 
in the beginning, preferably by a saline, cathartics are to be avoided. 

Appendicitis is a Burgical disease, and surgical advice should be 



INTESTINAL WORMS 423 

sought early. In deciding as to the time of operative interference, it 
should be remembered that localization of the inflammation is less likely 
to occur with children than with older patients and that therefore the 
dangers of general peritonitis are much greater; that the progress of the 
disease is much less regular; that grave conditions are not revealed at 
once by grave symptoms; that the disease is an insidious one. and that 
to foretell the outcome even in the mildest cases is impossible. Taking 
all these things into account, we believe that immediate operation, once 
the diagnosis is made, is the course to be recommended in all cases of 
acute appendicitis in children. The younger the child the greater the 
urgency for operation. 

INTESTINAL WORMS 

Judging by published reports, intestinal worms are much more com- 
mon in Europe than in the northern part of this country. Id 18,000 
patients treated for medical diseases in our dispensary services in New 
York and Baltimore there was positive evidence of worms in but L35 
cases. Of these, 20 had tapeworms, 55 round worms, 56 thread worms 
and 4 both round and thread worms. In private practice among the 
better classes, worms are certainly rare. 

Cestodes — Tapeworms. — Cestodes are usually introduced into the 
body by the ingestion of some form of food containing larvae (cysticerci ) . 
The larva of the tenia solium is most frequently found in pork; that of 
the tenia medio canellata in beef; that of the bothriocephalus kit us in 
fish; that of the tenia cucumerina inhabits dog or cat lice, being intro- 
duced into the intestinal tract accidentally by the hands. Several varie- 
ties of tenia are found in the human intestine. 

Tenia Saginata or Mediocanellata — Beef Tapeworm. — Enfec- 
tion results from eating raw or partially cooked beef containing cys- 
ticerci. The worm is from twelve to twenty feet in length, and has s 
square pigmented head without hooks but provided with four suckers. 
The full-sized segments are from one-half to three-fourths of as inch 
long and about half as wide. 

Tenia Solium — Pork Tapeworm. — This is n rare form in Hid- 
dren, and comes from eating raw or partially cooked pork ot Bausage. 
It is from six to ten feet in length, the segments being Dearly Bquare. 
The head is about the size of a mustard seed and is pigmented. It also 
is provided with four suckers and a proboscis, surrounding wind) 18 ;i 
circle of about twenty-six hooklets. 

Tenia Cucumerina ob Eluptica.- -The Larvae of this form develop 
in a louse found on the skin of dogs and cats. Children who play with 
infected animals are the ones affected, the parasite being conveyed to 



424 DISEASES OF THE DIGESTIVE SYSTEM 

the mouth usually by means of the hands; it may thus be found even 
in young infants. This form of tenia is much smaller than either of 
the preceding varieties, the full length being only from six to twelve 
inches. 

Bothriocephalic Latus. — This is a rare form except in the sea 
countries of northern Europe and Switzerland, where it is said to be 
very common. The larvae are harbored by certain fish, by eating which 
when insufficiently cooked they are introduced into the body. The full- 
grown worm is from twenty-five to thirty feet in length. 

Tenia Nana. — The tenia nana, or dwarf tapeworm, is the smallest 
of all the cestodes. It is a narrow worm of one-half to three-fourths of 
an inch in length, and is composed of one hundred to two hundred 
segments. It has a slender neck and globular head which contains four 
suckers and twenty or thirty hooklets. The habitat of the nana is the 
upper part of the ileum where it is often found in immense numbers. 
A single stool may contain several hundred worms. The ova have two 
definite membranes within the inner one of which three pairs of hook- 
lets are found. The cysticercus stage of this parasite is not known. 
It is probable that infection occurs from swallowing the ova them- 
selves. As a similar parasite inhabits the intestinal tract of rats and 
mice it is possible that these animals play a part in transmission. 
From the observations of Schloss it seems probable that in the vicin- 
ity of New York this is the most frequent intestinal parasite of 
childhood. 

Symptoms. — The only positive evidence of tapeworm is the discharge 
of the worms or separated segments, either singly or in groups. Occa- 
sionally worms pass into the stomach and are vomited. Various abdomi- 
nal symptoms may be associated with worms, but most of these are very 
indefinite in character and are more often due to other causes. The 
most frequent symptoms are bad breath, various annoying sensations, 
colicky attacks, inordinate or capricious appetite, and diarrhea. Usu- 
ally, if the patient is in good health, no constitutional symptoms are 
seen. Sometimes, particularly with the bothriocephalus latus, there is a 
very grave degree of anemia. The increase in the number of eosinophile 
cells in the blood is of considerable diagnostic value. They frequently 
form from four to ten per cent of the leucocytes, while in normal blood 
the usual number is less than two per cent. Many cases are on rec- 
ord, some of them in children, in which the symptoms of pernicious 
anemia have been present and have disappeared after the expulsion of 
the tapeworm. Nervous symptoms are not so often seen as with round- 
worms, and will be discussed in connection with them. 

Treatment. — Prophylaxis requires the cooking of meat to a suffi- 
cient degree to destroy the cysticerci. There is especial danger in 



INTESTINAL WORMS 425 

eating raw pork or sausage; that from rare beef is much less. The list 
of drugs used for the expulsion of the worm is a long one ; probably 
the most efficient is the oleoresin of male fern ; it is, however, difficult to 
administer and it is very likely to provoke vomiting. It may be given 
in capsules containing TTL x to TTl xx, or in an emulsion made up with 
simple elixir and acacia, in which TTl v to TTL x are contained ir one 
dram. For a child of four years at least one dram of the male l'ern 
should be given in the course of six to eight hours. The vermifuge 
should be preceded by several hours' fasting, and the bowels previously 
opened by a laxative. The following plan of administration has been 
found satisfactory : a light supper of milk, and in the morning a saline 
laxative on rising, but no breakfast; after the saline has acted freely 
the remedy is to be given, and following the last dose, half an ounce of 
castor oil or some other active purge. The effect of the cathartic is 
aided by a large injection of warm soap and water. Only milk should 
be given that day. The fragments passed should be carefully examined 
to see if the head has been expelled, as the worm is very likely to be 
broken at the neck. If this occurs it will grow again, and in about 
three months segments will appear in the stool. Other drugs useful 
for tenia are pumpkin seeds which are given in powdered form, infusion 
of pomegranate root, turpentine, and chloroform. 

Nematodes, — Three varieties are found in the intestinal canal, the 
ascaris lumbricoides, the oxyuris vermicularis, and the uncinaria 
Americana. 

Ascapjs Lumbricoides — KouxDwoRM. — This worm is usually found 
in the small intestine. It is much more frequently met with in children 
than is the tapeworm. It is exceedingly rare in infancy, but is usually 
seen between the third and tenth years. In over two thousand autopsies 
upon infants we have only twice found a roundworm in the intestine. 

The roundworm resembles the ordinary earthworm; it is from five 
to ten inches long, the female being longer than the male. It is of a 
light gray color with a slightly pinkish tint, cylindrical, and tapering 
toward the extremities. The eggs are oval in form, about ( 4 \ inch in 
diameter, and numbered by millions. These worms rarely exist singly; 
usually from two to ten are present, but there may be hundreds. When 
very numerous they coil up and form large masses, which may cause 
intestinal obstruction. 

The migration of these worms is curious, and in some instances truly 
remarkable. They frequently enter the stomach and are vonlited. 
sionally one may appear in the nose. They have been known t.. pass 
through the Eustachian lube into the middle ear and to appear in the 
external meatus. Entering the larynx they have produced fatal as- 
phyxia. It is not very rare for them to enter the common bile duet 



426 DISEASES OF THE DIGESTIVE SYSTEM 

and produce jaundice. They may even enter in great numbers the 
smaller bile ducts and produce hepatic abscesses. They have been 
found in the pancreatic duct, in the vermiform appendix, and in the 
splenic vein. It has long been known that they would perforate an 
intestine which was the seat of ulceration, but well-authenticated cases 
have been reported in which they have perforated an intestine previ- 
ously healthy, setting up a fatal peritonitis. In Archambault's case 
they perforated the stomach. In cases of a persistent Meckel's diverticu- 
lum, worms have been discharged from an umbilical fistula. They have 
been found in umbilical abscesses. Considering, however, the frequency 
of roundworms, migrations are rare. 

Symptoms. — The symptoms of roundworms are of the most in- 
definite kind; often there are none until the worm is discovered in the 
stools. It is then fair to assume that other worms are also present. The 
most frequent abdominal symptoms are colic, tympanites, and other 
symptoms of indigestion, loss of appetite, disturbed sleep and grinding 
of the teeth at night. These symptoms are much more frequently due 
to other causes than to worms, but when all are present the existence of 
worms should be suspected. 

A great variety of nervous symptoms may be associated with intes- 
tinal worms. They are more often seen with lumbricoids than with 
either of the other varieties. The symptoms may be of the most puzzling 
character, and may simulate very closely those of serious organic dis- 
ease. There may be prolonged low fever, chills, headache, vertigo, hal- 
lucinations, hysterical seizures, epileptiform attacks, convulsions, tetany, 
transient paralyses such as strabismus, and even hemiplegia and aphasia. 
All these have been observed in connection with intestinal worms, and 
from the fact that the symptoms disappeared completely after the worms 
were expelled, there seems to be but little doubt that they were the cause 
of the symptoms. As in the case of the abdominal symptoms, however, 
intestinal worms are only one of the causes of such nervous disturbances, 
and certainly not a frequent one; but the possibility that nervous dis- 
turbances may depend upon worms should not be overlooked. The blood 
generally shows eosinophilia, as in patients with tapeworm. 

The only positive evidence of the existence of roundworms is the dis- 
charge of a worm from the body, or the discovery of the ova in the stools. 
A microscopic examination of the stools is a valuable means of diagnosis, 
and one that is too infrequently employed. When worms are present the 
ova may be found in great numbers. Their continued presence, after the 
discharge of one worm, indicates that other worms remain. 

Treatment. — An efficient agent for the removal of the worms is 
santonin. The same plan of administration may be followed as in the 
case of the tapeworm, viz., to give the drug on an empty stomach, 



INTESTINAL WORMS 427 

preceded by a laxative. Santonin is best given in powdered form mixed 
with sugar. For a child of five years as much as three grains are usuallv 
required. This amount should be given in three doses at intervals of 
four hours, soon followed bjr a purge of calomel or castor oil. Oil of 
chenopodium is somewhat easier of administration and is quite as effi- 
cient. It may be given as described under the treatment for Hookworm. 
The great difficulty with santonin is its tendency to provoke vomiting. 
Occasionally in susceptible children, even with ordinary doses, toxic 
symptoms may develop, such as yellow vision, dark-red or yellow urine, 
and nervous excitement or delirium. 

Oxtubis Vebmiculabis — Pixwobm — Threadworm. — The oxyurie 
resembles a short piece of white thread. The female is about one-third 
of an inch long, the male about one-half that length, but is less fre- 
quently seen. The worm tapers toward the tail. The ova are of slightly 
irregular size, and are considerably smaller than those of the round- 
worm. 

The oxyuris inhabits the rectum, the cecum, and, according to Still. 
very frequently the appendix. These worms may be found also in the 
lower small intestine, in the stomach, and even in the mouth. If present 
in the rectum they are usually discovered by separating the folds of the 
anus. The number of worms is usually large. The irritation to which 
they give rise causes a great production of mucus, and frequently leads 
to a chronic catarrh of the colon of considerable severity. The worms 
are imbedded in the mucus; often they form with it small balls. Ac- 
cording to Leuckart, they are incapable of multiplying in situ. Doubi 
has recently been thrown upon this view by the observations of Still. 
From the immature character and the large numbers of the worms 
found in the appendix (111 in one case), this writer believes that the 
appendix may be a breeding place. The ova as well as the worms afire 
passed in enormous numbers with the stools. They attach themselves 
to the folds of the skin, the hairs about the anus, and even to the genitals. 
The patient may, through lack of cleanliness of the parts, continually 
re-infect himself. After discharge from the body, the ova may be 
carried by flies and deposited upon fruits, vegetables, or in drinking 
water. 

Symptoms. — The principal local symptom caused by the oxvuris is 
itching of the anus or the genitals. This is caused by the migration of 
the worms from the bowel, and usuallv cornea on at about the -am.' hour 
at night, generally soon after the patient has retired. It is sometime 
intense as to be almost intolerable. It leads t<> frequenl micturition, t<» 
incontinence of urine, in the male to balanitis, and in the femali 
vaginitis or vulvitis, and in both, hut especially in the latter, it may !><• 
the cause of masturbation. Owing to the catarrhal colitis which is 



428 DISEASES OF THE DIGESTIVE SYSTEM 

cited, there is discharged from time to time a large quantity of mucus. 
Severe colicky pains are often associated. The irritation may lead to 
prolapsus ani. Nervous symptoms are not so frequently associated 
as with the other varieties of worms, although we have seen at least 
one case of chorea in which they were almost certainly the cause. They 
have been known to excite convulsions. The general health is some- 
times undermined and there may be marked and progressive loss in 
weight. 

Treatment. — This is usually spoken of as a very simple matter, and 
no doubt in recent cases, or where the number of worms is small, this is 
true; but where the number is large, and considerable catarrhal inflam- 
mation of the colon is present, it is often a matter of the greatest diffi- 
culty to rid the bowel of these parasites. Cases frequently resist treat- 
ment by injection for months, even though thoroughly used. The reason 
for this is, that only the lower colon is reached by injections while the 
worms may be chiefly in the cecum or even in the appendix and small 
intestine. While, therefore, injections are important and indeed invalu- 
able, they can not be relied upon exclusively. The most scrupulous atten- 
tion to cleanliness is an absolute necessity as the first step in the treat- 
ment of all cases. It is well to bathe the parts about the anus after each 
stool, and even two or three times a day, with a bichlorid solution, 1 to 
10,000. Itching is best controlled by the application of mercurial oint- 
ment to the folds of the anus at bedtime, this effectually preventing the 
escape of the worms from the bowel. The local application of cold will 
sometimes have the same effect. The most efficient of the injections is 
probably the bichlorid. The colon should first be thoroughly cleansed by 
an injection of lukewarm water containing one teaspoonful of borax to 
the pint, in order to remove the mucus. When this has been discharged, 
half a pint of the bichlorid solution of the strength mentioned should be 
injected high into the bowel through a catheter, and retained as long 
as possible. This should be repeated every second or third night. On 
other nights a simple saline injection may be employed. The infusion of 
quassia, asafetida, aloes, and garlic are also useful. Solutions of car- 
bolic acid should never be employed. 

When the worms are high in the colon, drugs by the mouth must 
be combined with injections. The most efficient remedies are santonin 
and the oil of chenopodium, which may be used as for roundworms. 
The expulsion of the worms is aided by saline cathartics ; simple bitters, 
such as gentian and quassia, are also of some value. We have known 
one case, which resisted for over two years everything which had been 
tried, to be cured in two or three weeks by injections of a decoction of 
garlic, in connection with which garlic was given in liberal quantities 
by the mouth. 



INTESTINAL WORMS 429 

Uncinaria Americana or Hookworm.— This belongs to the class 
of nematodes. The males are one-fourth to one-half inch in length and 
the females slightly longer. The parasite resembles the ankylostomum 
duodenale of Europe. Infection usually takes place through the skin 
of the bare feet, more rarely that of the hands. It is possible, however, 
to contract the disease by eating dirty fruit or vegetables contaminated 
by the developing larvae; but infection does not occur from swallowing 
the ova or young larvae. After entering the skin the larvae find their 
way into the circulation and thus reach the lungs. From the lungs they 
may migrate or be coughed up into the mouth and then swallowed. 
They are not acted upon by the gastro-intestinal secretions, and in the 
upper part of the small intestine they develop into mature worms. 
These may exist in the small intestine for years. 

The symptoms in the milder cases are minor digestive disturbances, 
general malnutrition with moderate anemia and arrested growth. In 
the more severe cases the anemia is very marked, the hemoglobin often 
falling to thirty per cent or below. The leucocytes are normal in num- 
ber or slightly increased; but the percentage of eosinophiles is above the 
normal. In most patients the proportion reaches five or ten per cent; it 
may however be twenty-five per cent or even higher. Edema of the face 
is common and there may be general dropsy without albuminuria. Af- 
fected children besides being very backward in physical development, are 
dull, inattentive and entirely wanting in physical or mental energy. 
The appetite is sometimes absent; but more characteristic is the crav- 
ing, not only for every kind of food, but for such articles as clay, dirt, 
chalk, etc. Death may be due to the progressive failure of nutrition 
or to intercurrent disease. 

Prophylaxis in the individual consists chiefly in the protection of the 
feet of persons living in an infected district, by wearing shoes. The 
chief remedy for the hookworm is thymol. Its administration should be 
preceded by one or more full doses of the sulphate of magnesia <>r Boda 
given after twelve hours' fasting. The quantity of thymol given to a 
child of five years should be six or eight grains in divided dosea in the 
course of three or four hours. It may be administered cither in capsule 
or in suspension. Two hours after the last dose, the salts should be 
repeated; but no food should be given until the cathartic has acted freely. 
Castor oil should not be used. A repetition of the treatment is often 
necessary before a cure is accomplished. 

The oil of chenopodium is apparently quite as effective as thymol 
and has the advantage of being much cheaper. It may be administered 
dropped upon sugar. The usual dosage is one drop per year of age up 
to ten years. A dose of Epsom salts is given on the preceding day and 
three doses of the oil at two-hour intervals the next morning, the last 



430 DISEASES OF THE DIGESTIVE SYSTEM 

dose to be followed by castor oil. It should be remembered that cheno- 
podium is toxic in over doses. 



CHAPTER X 

DISEASES OF THE RECTUM 

PROLAPSUS ANI 

Under this term are included two conditions. In the first, or partial 
prolapse, there is simply an eversion of the mucous membrane which 
protrudes be}^ond the sphincter. In the second, or complete prolapse, 
there is invagination of the rectal wall for a variable distance, usually 
two or three inches. 

Etiology. — Prolapse is most common in children during the second 
and third years. Its frequency in early life is partly due to the lack 
of support furnished by the levator-ani muscles. It also occurs very 
readily when the ischiorectal fat is scanty; it is therefore often seen in 
children suffering from marasmus. The exciting cause may be anything 
which provokes severe and prolonged straining. This may be either the 
tenesmus accompanying inflammation of the rectal mucous membrane 
or chronic constipation. It may come from phimosis or stricture of the 
urethra, and it is a very frequent symptom of stone in the bladder. 

Symptoms. — Prolapse usually occurs during the act of defecation. It 
is generally easily reduced, but shows a great disposition to return with 
every stool. In obstinate cases the bowel comes down at other times. 
The appearance of the tumor varies with its size. In the slighter form 
there is simply a ring composed of a fold of mucous membrane sur- 
rounding the anus. In the more severe form there is a flattened, corru- 
gated tumor, usually about the size of a small tomato. The mucous 
membrane covering the tumor is of a deep purplish-red color, and bleeds 
readily. It may be the seat of catarrhal or membranous inflammation. 
The diagnosis in most cases is easy, although the tumor has been con- 
founded with polypus and intussusception. 

Treatment. — In most cases reduction is easily accomplished by laying 
the child upon his face across the lap, and making gentle pressure upon 
the tumor with oiled fingers. The application of cold, either by means 
of ice or cold cloths, is of assistance in cases which are not at once re- 
duced by pressure. After reduction, in the milder cases the child should 
be kepi upon his back for at least an hour. When the tumor tends to 
come down with every stool, special attention should be given at this 



FISSURE OP THE AXUS 431 

time. If an infant, the bowels should always move while the child lies 
upon his back, and during defecation the buttocks should be pressed to- 
gether by a nurse. Older children should use an inclined seat placed at 
an angle of about forty-five degrees, but should never sit upon a low 
chair or assume any position in which straining is easy. After defecation 
the patient should lie down for at least half an hour. When there is 
constipation, the bowels should be kept free by means of laxatives. If 
there is diarrhea, tenesmus may be overcome by frequent sponging 
with ice water, or by the use of small injections of ice water and tannic 
acid, in the proportion of twenty grains to the ounce. In more severe 
cases it may be controlled by the use of suppositories of opium. When 
the bowel tends to come down frequently, this may be prevented by the 
use of an adhesive strap two or three inches wide, placed tightly across 
the buttocks. This is better in the milder cases than a T-bandage. The 
great majority of the cases are cured by these means in the course of a 
few weeks. 

In the most severe cases the bowel not only protrudes during defeca- 
tion, but also in the interval, and it may be down for days at a time. 
Such cases are rarely seen except in infants who have very flabby muscles, 
and but little adipose tissue at the floor of the pelvis. Reduction is 
sometimes difficult in cases when the prolapse has lasted a long time. It 
is often facilitated by painting the protruding part with a solution of 
epinephrin, and then dilating the sphincter by passing the finger 
into the central opening of the tumor. After reduction, suppositories 
containing from one-fourth to one-half grain of cocain may be inserted. 
They are more efficient than those containing opium or belladonna. A 
firm pad should be applied over the anus, held in position by a T-bandage. 
For several days at a time a short rubber tube may be kept in the rec- 
tum, held in place by adhesive plaster. The bowels should be kept freely 
open. Where all other measures fail, the protruding pari may be 
touched with the Paquelin cautery, linear markings being made ;ii in- 
tervals of an inch. Amputation or excision is not required in children. 



FISSURE OF THE ANUS 

This is not a very uncommon condition in children. The most fre- 
quent cause is the passage of a large, hard, fecal mass. Sometimi 
results from traumatism inflicted with the nozzle of a Byringe while 
giving an enema. It may be prodnced by the scratching excited by pin- 
worms. In the beginning there ia a simple (ear at the margin of tin- 
anus. The laceration which is produced usually healfl promptly; but if 
the cause is repeated, healing is prevented, and there is finally prodnced 



432 DISEASES OF THE DIGESTIVE SYSTEM 

a linear ulcer, or a true fissure, which may last for some time and be 
a source of great annoyance. 

A fresh fissure has the appearance of any other tear at a mucocuta- 
neous orifice. One of longer standing has a gray base, slightly indurated 
edges, often discharges a small amount of pus, and bleeds a drop or two 
with nearly every movement of the bowels. The most constant symptom 
is pain, which usually occurs with the act of defecation and continues 
for some time afterward. It is most severe when the fissure is just at the 
margin of the sphincter, and leads the child to resist every inclination to 
have the bowels move, so that it becomes a cause of chronic constipation, 
which condition again greatly aggravates the fissure. The pain is often 
referred to other parts in the neighborhood. 

The treatment is simple and usually efficient. It consists in clean- 
liness, overcoming the constipation, and touching the fissure with nitrate 
of silver, preferably with the solid stick. If the case is not speedily 
relieved by such measures, the sphincter should be stretched as in adult 
patients. 

PROCTITIS 

Proctitis, or inflammation of the rectum, usually occurs with inflam- 
mation of the rest of the large intestine, but it may occur alone. It is 
to the cases in which only the rectum is involved that the term is gen- 
erally applied. 

The causes are for the most part local. A frequent one in infants 
is the use of irritating injections or suppositories, either for the relief of 
constipation or as a means of administering certain drugs. We have seen 
one obstinate case in an infant a year old, following the prolonged use of 
glycerin suppositories. It is sometimes caused by traumatism, especially 
by the careless giving of an enema. It accompanies pinworms. In 
certain cases it may result from direct infection through the anus. This 
may be from a gonococcus inflammation extending from the vagina or 
urethra, or from an infection due to other bacteria, particularly in cases 
of measles, scarlet fever, and diphtheria; or, finally, it may be due to 
syphilis. Proctitis may be catarrhal, membranous, or ulcerative. 

Catarrhal Proctitisu — The pathological conditions are the same as in 
ordinary catarrhal inflammation of the intestinal mucous membrane. By 
the introduction of a speculum, or by simply everting the mucous mem- 
brane, it is seen to be reddened, swollen, and bleeds easily. There is a 
copious secretion of mucus. In cases of long standing there may be 
superficial ulceration appearing as a white or yellowish-white surface, 
usually just inside the sphincter. 

The symptoms are chiefly local, although a condition of general irri- 



PROCTITIS 433 

tability may result from the local condition. There is heightened reflex 
action, so that the stool often comes with a spurt. There is pain with 
defecation, and mucus is discharged, usually as a clear, jelly-like mass, 
and sometimes in the form of a cast, but not generally mixed with the 
stool. There are usually traces of blood, sometimes quite large hemor- 
rhages. In the most acute cases, tenesmus is present both during and 
after the stool. There may be prolapsus ani. The skin in the vicinity is 
irritated by the discharges, most frequently so in infants. If the cause 
is pinworms, there may be intense itching. The duration of the disease 
is indefinite, depending upon the cause. It may be a few days or many 
months. The inflammation may extend from the rectum to neighboring 
parts, leading to ischiorectal abscess. 

Membranous Proctitis. — It has been customary to describe this as a 
complication of diphtheria, usually occurring with diphtheria of the ex- 
ternal genitals. As few of these cases have been studied bacteriolog- 
ically, it is impossible to say what proportion of them, if any, are to be 
regarded as true diphtheria. When the infection is from the intes- 
tine above, the rectum is never affected alone. When it is from below, 
this may be the case. The lesions are the same as in membranous in- 
flammation occurring higher in the colon. The symptoms resemble those 
of the catarrhal variety with the addition that the stools contain pieces 
of pseudo-membrane. This can be made out only by repeatedly washing 
the discharges with water. If accompanied by prolapse, the pseudo- 
membrane may be seen. Membranous proctitis may be complicated by 
a membranous inflammation of the genitals or the perineum. Although 
it is usually acute, it may last for weeks. 

Ulcerative Proctitis. — Ulcers of the rectum may be the result of a 
catarrhal inflammation; these, however, are usually superficial, affecting 
the mucous membrane only, and in most cases heal rapidly. Sometimes 
they extend more deeply into the submucous or even the muscular coat. 
They are then chronic, often very obstinate, and may last indefinitely. 
Follicular ulcers of the rectum are nearly always associated with the 
same condition in the sigmoid flexure. These are always multiple and 
usually small, rarely being more than a quarter of an inch in diameter. 
Sometimes the small ones coalesce, producing much larger ulcers. Single 
ulcers may be of tuberculous origin. Syphilitic ulcers are extremely 
rare in children. 

The symptoms of ulcer of the rectum are mainly two — pain and hem- 
orrhage. The pain is of variable intensity, and may he referred to the 
coccyx, or to any of the neighboring parts. The amounl of bleeding 
may be small, the blood coming in clots, or it may he fluid and ii 
large a quantity as to produce general symptom-. It usually accom- 
panies every stool. In addition the stool contain- more or less pufl, par- 



434 DISEASES OF THE DIGESTIVE SYSTEM 

ticularly in chronic cases. When the ulcer is low down, tenesmus is 
usually present and may be a prominent symptom. The duration of 
the symptoms is indefinite; often they last for many months and lead 
to a marked deterioration in the general health. A positive diagnosis 
of ulcer can be made only by examination with a speculum. 

Treatment. — In cases of acute catarrhal proctitis injections of some 
bland fluids should be employed, such as a starch-water, limewater, a mix- 
ture of oil and limewater, or a warm one-per-cent saline solution. The 
local cause, if one exists, should be removed. In the most acute cases 
the patient should be kept in bed. When the tenesmus is severe, sup- 
positories of opium may be used. In the more chronic cases saline 
injections should be given, and followed by a mild astringent like tannic 
acid, ten grains to the ounce, or a . one-per-cent solution of hamamelis. 
Cases associated with pinworms are especially obstinate. Here the treat- 
ment is first to be directed to the worms, and afterward to the proctitis. 

In the membranous cases the same measures are to be employed, and 
in addition the injection of a warm boric-acid solution two or three 
times a day. 

Cases of ulcer require the most careful treatment. In many there is 
but little tendency to spontaneous recovery. An examination with the 
speculum should be insisted upon in all cases of chronic proctitis, to 
make sure of the diagnosis. Rest in bed is essential to a rapid improve- 
ment. The bowels should be kept freely open by the use of laxatives and 
injections of a boric-acid solution, or one or two ounces of liquid albolene 
may be injected every night and retained. If this does not relieve the 
patient, a weak solution of nitrate of silver (one grain to the ounce) 
may be injected daily after washing out the bowel with tepid water. 
If a stronger solution than this is used, it should be neutralized after 
half a minute by the injection of a saline solution. 



ISCHIORECTAL ABSCESS 

This is not a very rare condition even in infancy. Infection from the 
rectum, usually through the lymph channels, seems to be the most com- 
mon cause, although sometimes the abscess may be traced directly to trau- 
matism. 

Essentially the same varieties of inflammation are seen in early life as 
in adults. Most of these cases recover promptly after simple incision 
and cleanliness, fistula being a rare sequel. 



INCONTINENCE OF FECES 43.3 

RECTAL POLYPUS 

Polypi are rarely seen in children, but, when present, may be the 
canse of rather obscure symptoms. The most important one is hemor- 
rhage. This at first occurs at intervals of days or weeks. The amount 
of blood lost is from a dram to an ounce or more. Later, the hemor- 
rhages become more frequent and may be almost continuous, although 
rarely profuse enough to produce serious symptoms. The diagnosis of 
polypus is made only after a local examination. Sometimes the tumors 
are within the reach of the finger; in other cases a proctoscope must be 
employed. Spontaneous cure often takes place by the sloughing of the 
tumor, after which the bleeding soon ceases. In other cases operation 
is necessary. 

HEMORRHOIDS 

These, fortunately, are not often seen in children, although they occur 
in those as young as three or four years, and in some cases may even be 
congenital. The principal cause is chronic constipation, rarely diarrhea. 
The tumors are generally small and external, the chief symptom com- 
plained of being pain on defecation. Bleeding sometimes accompanies 
the pain, but the hemorrhages are usually small. The treatment is to be 
directed toward the underlying cause. In most of the cases this suffices 
to cure the condition. Operation is rarely required in young children, 
although neglect may make this procedure necessary. 



INCONTINENCE OF FECES 

Inability to control the fecal evacuations is seen in certain cases of 
paraplegia due to myelitis, after injury of the lumbar portion of the 
spinal cord, and in spina bifida. It may occur with the usual or with the 
occult variety, associated with incontinence of urine, when there ifl DO 
paralysis of the extremities. It is also seen in acute disease, as in tin- 
coma of meningitis, and occasionally in the typhoid condition and in 
extreme adynamia, from any cause. It is quite common in severe attacks 
of chorea. It may sometimes he seen after operations for atresia <>f the 
anus or rectum. In all these conditions incontinence of feces ia 8 
symptom giving rise to much annoyance and Deeding careful attention. 
Uncleanliness with reference to excreta, seen in idiocy, can hardly !»«• 
classed as incontinence. 

Besides these familiar forms, the condition is sometimes Been from 



436 



DISEASES OF THE DIGESTIVE SYSTEM 



causes somewhat resembling those of incontinence of urine. The tone 
of the sphincter becomes so feeble that it does not resist even the slightr 
est impulse to evacuate the rectum. The discharge may take place with 
but little warning, and may occur either by day or night. In some cases 
a local cause exists, such as stretching of the sphincter by an old rectal 
prolapse. It has followed overdistentipn of the rectum from prolonged 
chronic constipation. Ostheimer reports a case in which a vesical cal- 
culus was present. It is sometimes seen after severe acute illness, as a 
result of a loss of general muscular tone. In certain children it has been 
known to persist from infancy until the age of ten or twelve years. It 
may come on as a somewhat acute condition in highly nervous patients 
with poor general nutrition. The causes are chiefly of local and nervous 
origin. The treatment is rather unsatisfactory, except in recent cases 
and in those due to local causes which can be removed. If constipation 
exists the rectum should be emptied daily, preferably by an enema. 
The remedies which have proven most successful are strychnia, ergot, 
and belladonna, but they must be given in full doses, sometimes advan- 
tageously by suppository as well as by mouth. The general health should 
receive careful attention. 



CHAPTER XI 
DISEASES OF THE LIVER 

Aside from the different forms of degeneration which are seen in the 
various infectious diseases, the liver is not often the seat of serious dis- 
ease in infancy and early childhood. In later childhood nearly all the 
forms seen in adult life are occasionally met with, although even then 
they are quite rare. 

Size and Position. — The weight of the liver in the newly-born child, 
from one hundred and seven observations of Birch-Hirschfeld, is 4.5 
ounces (127 grams), or about 4.2 per cent of the body weight. The 
accompanying table gives the results of one hundred and seventy-four ob- 



Age. 


Average. 


Per cent of 


Ounces. 


Grams. 


body weight. 


3 months 


6.3 

7.5 

11.0 

14.0 

16.0 


180 

212 
311 
397 
453 


3 1 


6 " 


3.0 
3.40 
3 37 


12 " 


2 years 


3 " 


3.26 





CATARRHAL JAUNDICE 437 

servations upon the liver in infancy in the autopsy room of the New 
York Infant Asylum. 

In adults, according to Frerichs, the weight of the liver is about 2.5 
per cent of the weight of the- body. 

The upper border of the liver is best made out by percussion. In the 
child, the upper limit of the liver dulness in the mammary line is found 
in the fifth intercostal space; in the axillary line, in the seventh space; 
posteriorly, in the ninth space. The lower border is best determined by 
palpation. This, as a rule, in the mammary line is found about one-half 
an inch below the free border of the ribs. According to Steffen, the left 
lobe is relatively larger in the child than in the adult. The liver may be 
displaced downward by contraction of the chest, as in rickets, or by an 
accumulation of fluid in the pleural cavity. It is frequently found lower 
than normal in conditions of great emaciation, owing to relaxation of the 
abdominal walls and its ligamentous supports. Upward displacement 
is much less frequent, and depends usually upon ascites or abdominal 
tumors. 

Malformations and Malpositions. — Congenital malformations relate 
chiefly to the bile ducts. These have been considered in the chapter de- 
voted to Icterus in the Newly Born. 

The liver may be found upon the left side in cases of general trans- 
position of the viscera. In diaphragmatic hernia it has been found in 
the thoracic cavity. 

CATARRHAL JAUNDICE 

This is due to a catarrhal inflammation of the common bile duct 
with which there is usually associated a similar inflammation of the 
duodenum and sometimes of the stomach also. The term gastro- 
duodenitis is sometimes used synonymously with catarrhal jaundice. 
The jaundice in these cases is due to obstruction which is caused by 
swelling of the mucous membrane of the bile duct. Catarrhal jaundice 
is rare in infancy. In children from three to six years old it is not un- 
common, and curiously occurs much more frequently in the fall months. 
This suggests an infectious origin. For the most part its causes are 
obscure. 

It occasionally complicates malarial fever and may occur with any of 
the infectious diseases. Rehn has described a form which occurred 
epidemically. 

The symptoms of the disease are quite uniform. When primary, the 
onset is like an ordinary attack of indigestion, with vomiting, pain, 
slight fever, and a moderate amount of prostration. The vomiting in 
some of the cases is repeated for several days. The pain may he quite 



438 DISEASES OF THE DIGESTIVE SYSTEM 

severe, and localized in the region of the duodenum. It may be asso- 
ciated with tenderness in this region. The bowels are usually consti- 
pated. After three or four days, icterus, which is the only diagnostic 
symptom, appears. It is first seen in the conjunctivae, afterward in the 
skin, varying in degree according to the severity of the attack, but in 
most cases not being very intense. It is accompanied by the regular 
symptoms of obstructive jaundice. The stools are gray, sometimes white ; 
there is a marked amount of intestinal flatulence. The urine is very 
dark, of a yellowish-green or bronze hue, and stains the clothing. There 
is complete anorexia; the tongue is thickly coated with a white fur. 
Headache, dulness, and languor are present, and the patient feels 
wretchedly. The slow pulse and the itching skin are uncommon symp- 
toms in children. The liver is usually found slightly enlarged, and some- 
times tender on pressure. The duration of the disease is about two weeks, 
the general symptoms disappearing before the icterus. Eecurrences and 
prolonged attacks are occasionally seen. The diagnosis rarely presents 
any difficulty, and the prognosis is invariably good. 

The fats and starches of the food should be reduced to a low point 
or be entirely prohibited. Patients usually do much better upon a diet 
of rare meat, fruit, and skimmed milk, or buttermilk. If there is very 
much vomiting, food should be temporarily withheld and later skimmed 
milk should be given largely diluted with limewater. The amount of 
food given should be small, but water should be allowed freely, par- 
ticularly the alkaline mineral waters. The bowels should be kept open, 
if necessary by means of cathartics. In most of the cases no other treat- 
ment is necessary. When the pain is severe it may be relieved by coun- 
ter-irritation by mustard, turpentine, or even cantharides. The restricted 
diet should in all cases be continued for at least a week after the jaun- 
dice has disappeared. 

NEW GROWTHS 

New growths of the liver are rare in children and are usually sec- 
ondary to deposits elsewhere, most frequently in the kidney. They are 
generally sarcomatous. Primary sarcoma of the liver has, however, been 
observed, and at so early an age as to make it practically certain that 
the condition was a congenital one. In most of the cases there is simply 
a slowly increasing abdominal tumor and progressive asthenia. 



ACUTE YELLOW ATROPHY 

'IMi is form of hepatic disease is rare in children. Greves has re- 
ported ;i well-marked case in an infant of twenty months, and has 



ABSCESS OF THE LIVER 439 

collected seventeen other cases under ten years of age; the youngest was 
in an infant three months old. The symptoms and course of the disease 
are essentially the same as in adults. A condition closely allied to this 
is occasionally seen as a result of the administration of chloroform. 



CONGESTION OF THE LIVER 

Congestion of the liver occurs from the same causes in children as 
in adults. Acute congestion is not often seen. Chronic congestion is 
more common, and is usually secondary to general venous obstruction de- 
pendent upon congenital or acquired heart disease, atelectasis, or other 
pulmonary conditions, particularly chronic pleurisy, chronic interstitial 
pneumonia and emphysema. Chronic congestion of the liver causes no 
characteristic symptoms except a moderate enlargement of the organ 
with some pain and tenderness. The treatment is that of the primary 
disease. 

ABSCESS OF THE LIVER— SUPPURATIVE HEPATITIS 

In 1890 Musser found hut thirty-four recorded cases of abscess of 
the liver in children under thirteen years. Since that time a few addi- 
tional cases have been reported. In the above collection, there have 
not been included cases of suppurative hepatitis occurring in the newly 
born. 

As in adults, abscess of the liver may result from traumatism, or it 
may be secondary to suppurative pylephlebitis, which depends upon a 
focus of infection in the umbilical vein, or in some part of the abdomen 
from which the branches of the portal vein arise. Pylephlebitis may fol- 
low appendicitis, it may follow typhoid fever directly, or be due to sup- 
puration of the mesenteric glands or peritonitis following typhoid. In 
seven of the cases collected by Musser the disease was due to migration 
of roundworms from the intestine into the hepatic duds. Menger 
(Texas) has reported one case following dysentery, the only one. we 
think, on record in this country. Very rarely greai numbers of minute 
abscesses are found as a. result of suppurative thrombosis of I be jugular 
bulb following middle ear disease. In quite ;> number of cases no ade 
quate cause can be found. 

In the cases occurring in pyemia and in those associated with pyle- 
phlebitis there are usually several abscesses; in traumatic cases generall} 
but one. If untreated, the majority of cases pro\e fatal either from ex- 
haustion or from rupture into the pleura or peritoneum. In Asch's 
case spontaneous cure took place by rupture into the intestine. 



440 DISEASES OF THE DIGESTIVE SYSTEM 

Symptoms. — Occasionally abscess of the liver is latent, bnt in most 
of the cases the symptoms are marked and sufficiently characteristic to 
make the diagnosis a matter of no great difficulty. The most constant 
general symptoms are chills, which may be single, bnt are usually re- 
peated ; fever, which is commonly of the hectic variety and followed by 
sweating ; prostration, vomiting, diarrhea, and cachexia. Jaundice is 
present in less than half the cases, and is rarely intense. The liver is 
almost invariably sufficiently enlarged to be easily made out by palpation 
or by percussion; the enlargement in most cases is chiefly downward. 
Pain is quite constant and frequently intense, but not always in the 
region of the liver. It may be in the epigastrium, at the umbilicus, in 
the lower part of the abdomen, and occasionally in the right shoulder. 
Tenderness over the liver is usually present. A positive diagnosis of 
hepatic abscess is to be made only by aspiration and the withdrawal of 
a fluid having the characteristics of "liver pus." Pulmonary symptoms 
usually exist with an abscess occupying the convexity of the right lobe. 
There may be cough and dyspnea from pressure, or pleurisy from ex- 
tension of the inflammation through the diaphragm, or from rupture 
into the pleural cavity. The usual duration of abscess of the liver after 
the beginning of the symptoms is from one to two months. The prog- 
nosis will depend upon the cause of the disease. The pyemic cases are 
usually fatal. In Musser's collection, the proportion of recoveries was 
about thirty per cent. At the present time, with improved methods of 
treatment and earlier diagnosis, the outlook is somewhat better than this. 

Treatment. — This is purely surgical, unless the abscess is due to an 
amebic colitis. In that case emetin hydrochlorid should also be given 
hypodermically as advised under amebic colitis. Cases have been re- 
ported where, after undoubted evidences of abscess have been present, 
recovery has ensued with the use of emetin alone. Without operation, 
however, the chances of recovery are slight. A small number of cases 
have been cured by aspiration, but in the vast majority of abscesses 
due to any cause only incision and drainage are to be depended upon, 
and, if the abscess is accessible, should be resorted to as soon as the 
diagnosis is established. 

CIRRHOSIS 

Cirrhosis of the liver is exceedingly rare in early life, although quite 
a number of cases are now on record between the ages of seven and four- 
teen years. Sixty-five have been collected by Howard and fifty-three by 
Laure and Honprat. Nearly all the cases in these collections were be- 
tween nine and fifteen years old. Cirrhosis in infancy is usually of 
syphilitic origin. Two-thirds of those in Howard's collection were males. 



AMYLOID DEGENERATION OF THE LIVER 441 

The etiology in most of the eases is obscure; in over half of those re- 
ported no cause could be discovered. Fifteen per cent of Howard's 
cases were traced to alcoholism, eleven per cent to syphilis, and eleven 
per cent to tuberculosis. Laure and Honorat believe that the eruptive 
fevers sometimes play an important part as an etiological factor, and 
that at other times the cause is possibly malaria. 

The anatomical features of cirrhosis in early life are essentially the 
same as in adults. The liver is sometimes enlarged, but usually it is 
smaller than normal. The connective tissue may be distributed around 
the lobules, along the bile ducts, in irregular patches, or in striatums 
through the organ. Associated with this there is atrophy and fatty 
degeneration of the liver cells. In some of the cases reported there lias 
been also a similar increase in the connective tissue of the spleen and 
kidneys. 

Symptoms. — These are very much the same as in adult life. In the 
beginning there are the indefinite disturbances referable to the digestive 
organs, and the liver may be slightly enlarged; later there is ascites, 
enlargement of the spleen, and dilatation of the abdominal veins. Ascites 
is a pretty constant symptom, and is generally marked. Slight icterus 
is often present, but a marked amount is rare. There may be hemor- 
rhages from the stomach, from the nose, or from other organs ; in a few 
cases there is slight fever. The late symptoms are, a small liver, marked 
ascites with the consequent embarrassment of respiration, cachexia, and 
sometimes general dropsy. Diarrhea is a much more constant symptom 
than in adults. Death usually takes place from exhaustion. The course 
of cirrhosis in children is commonly more rapid than in adults, and the 
progress is steadily downward. 

Treatment. — Medicinal treatment is of avail only with patients who 
are syphilitic. These should be put upon antisyphilitie remedies in full 
doses. The treatment in other respects is symptomatic and palliative. 
The ascites may require paracentesis as in adults. 



AMYLOID DEGENERATION (Waxy or Lardaccous Liver) 

From the experiments of Krawkow, Davidsohn, and others there 
seems now little doubt that amyloid degeneration can he produced by the 
prolonged action of the staphylococcus aureus, mid probably by other 
organisms. Amyloid degeneration of the liver is associated with similar 
changes in the spleen and kidneys, and sometimes in the villi of the -mall 
intestine, and is usually seen in children after long-continued suppura- 
tion in chronic bone or joint disease, empyema, tuberculosis, or Byphilis. 

The liver is generally very much enlarged ; in extreme casea a wreighl 



442 DISEASES OF THE DIGESTIVE SYSTEM 

of six or seven pounds may be reached. It is of a glistening, waxy ap- 
pearance, very firm and hard. With a solution of iodin, a mahogany- 
brown reaction is obtained. The amyloid substance is deposited between 
the capillaries and the hepatic cells, leading to occlusion of the vessels 
and atrophy of the cells from pressure. 

Amyloid liver per se produces few symptoms. Ascites is rarely pres- 
ent except in cases in which the liver is very large, and jaundice does not 
occur. In addition to the symptoms of the original disease in the 
course of which the amyloid degeneration occurs, there is the peculiar 
waxy cachexia which is seen in no other condition, but resembles some- 
what that belonging to malignant disease. The face has the appearance 
of alabaster, and the skin has a singular translucency. The liver may be 
so large as to form a tumor, sometimes nearly filling the abdominal 
cavity. Not infrequently it extends to the umbilicus, and even to the 
crest of the ilium. The surface is smooth and hard, and the edges usu- 
ally rounded. There is no localized pain or tenderness. The spleen is 
invariably enlarged. As a result of the associated amyloid degeneration 
of the kidney, there may be anasarca and albuminuria. Dropsy may 
occur from pressure of the large liver upon the vena cava, apart from 
the condition of the kidney. 

Amyloid changes usually take place slowly, the whole course of the 
disease being marked by years, the patient dying from slow asthenia, 
from nephritis, or from some acute intercurrent disease. As a rule, cases 
go on steadily from bad to worse; but sometimes, after the disease has 
reached a certain point, the condition remains stationary for a long 
time. 

The prognosis is always bad, although in a few cases improvement, 
and even cure, are stated to have occurred after the excision of the dis- 
eased joints upon which the amyloid degeneration depended. When due 
to syphilis, the usual antisyphilitic remedies should be given. 



FATTY LIVER 

Fatty infiltration of the liver is generally a secondary condition in 
early life, and causes no symptoms by which it can be positively recog- 
nized. Considerable discussion has of late arisen regarding its frequency 
in in Fa nls. From our records at the Babies' Hospital, Wollstein has 
tabulated 345 consecutive autopsies in which the condition of the liver 
was carefully noted. The liver was fatty in 201, or 58 per cent. Of 
iIk-sc autopsies. 63 were cases of tuberculosis, in 43 of which, or 68 per 
centj the liver was fatty. 

The general nutrition of the 345 infants was as follows: 



BILIARY CALCULI 443 

Wasted 188: liver fatty, 104, or 55 per cent— very fatty in 17. 

Fairly nourished 80: " " 52, "65 " " " " " 9 

Well nourished 77: " " 45, "59 " " " " "20. 

These figures coincide very closely with the observations of Free- 
man at the New York Foundling Hospital, and indicate that fatty liver 
is not, as has been so often asserted, much more frequent in wasted 
infants than in others. The cause of this change in the liver is as yet 
but little understood. 

The liver is moderately enlarged, smooth, with rounded edges, of a 
yellowish-red or a lemon-yellow color, and can be indented with the 
finger. A warm knife becomes coated with oil after cutting. Microscop- 
ically there is seen an accumulation of fat in the liver cells, usually 
irregularly distributed, but chiefly in the periphery of the lobule. Jaun- 
dice, ascites, and the other peculiar symptoms of hepatic disease are 
absent. The liver is moderately increased in size. Its functions are not 
interfered with in such a way as to be recognized by the symptoms. 
The treatment is that of the original disease. 

HYDATIDS 

Echinococcus disease of the liver, while rare among adults in this 
country, is almost unknown in children. We have been able to find but 
two recorded cases in America. From twenty-two European cases col- 
lected by Pontou, it appears that unilocular cysts are especially frequent 
in young subjects. If the upper surface is affected, pulmonary symp- 
toms, cough and dyspnea, are usually present; if the under surface 
of the organ, there is pressure upon the portal vein, the vena cava, bile 
ducts, stomach, and intestines. This pressure may cause icterus, dilata- 
tion of the superficial abdominal veins, and sometimes ascites. The local 
signs are enlargement of the liver with a tumor, which is easily recog- 
nized in children because of the thin abdominal walls. The hydatid 
fremitus is usually obtained. By aspiration a clear fluid is withdrawn, 
showing under the microscope the presence of the booklets, which estab- 
lishes the diagnosis. Occasionally cure may take place by spontaneous 
rupture or. suppuration of the cyst, but in most cases, when left t<> itself, 
the disease proves fatal. The treatment is surgical, and consists in 
aspiration or in incision, and the evacuation of the cyst. 



BILIARY CXLCULI 



cni v ease 



Up to the age of puberty calculi are extremely rare. Of fcwi 
collected by Still, eleven occurred in newly-born infants 1 ave 



444 DISEASES OF THE DIGESTIVE SYSTEM 

symptoms during the first month of life. The prominent symptom was 
intense and persistent jaundice. Nearly all died within the first month, 
the autopsy usually showing multiple calculi in the common duct. 
The cases in older children do not differ from those in adults. 



CHAPTEE XII 
DISEASES OF THE PERITONEUM 

Inflammation" of the peritoneum is seen at all ages, even in the 
first weeks of life; but is less frequent in children than in adults since 
most of the causes which are operative in later life either do not exist 
at all in childhood or are infrequent. 

We shall consider separately acute, chronic, and tuberculous 
peritonitis. 

ACUTE PERITONITIS 

Acute peritonitis may occur at any period of infancy or childhood. 
It may even exist in intra-uterine life. In the newly born, peritonitis is 
not infrequent. After this time it is exceedingly rare during infancy, 
only four cases, including all varieties, being met with in 726 consecutive 
autopsies in the New York Infant Asylum. After the fifth year the 
disease is relatively much more common. Of the 187 cases above re- 
ferred to, 25 per cent occurred in the newly born, 21 per cent between 
one and five years, and 54 per cent between the fifth and the sixteenth 
years. 

Etiology. — In the newly born, peritonitis is seen as one of the fre- 
quent lesions of acute pyogenic infection. It is usually due to direct 
infection through the umbilical vessels. In infancy and childhood, 
peritonitis occurs both as a primary and secondary inflammation. The 
primary form is rare. It may be due to traumatism, such as falls or 
blows, or to surgical operations upon the abdomen ; it has occurred after 
an injection for the cure of a congenital hydrocele. Very rarely the 
inflammation seems to have been excited by exposure, and it may follow 
severe burns. Cases of acute peritonitis are occasionally seen which are 
apparently primary. We have met with four in young children, two 
being due to the pneumococcus and two to the streptococcus. 

The secondary form is more common. The most frequent of all 
causes is appendicitis, which should always be suspected in acute perito- 



ACUTE PERITONITIS 445 

nitis occurring without definite cause. Extension of inflammation from 
the viscera to the peritoneum is very much less frequent in children than 
in adults. It is very rarely seen as a complication of dysentery. It 
is also rare in typhoid fever. It is occasionally due to abscess of the 
liver, ulcer of the stomach, acute intestinal obstruction from internal 
strangulation, intussusception, volvulus, and congenital atresia. It may 
extend from inflammation of the pleura. This may be in the form of 
an empyema which burrows through the diaphragm, or, without bur- 
rowing, the infection may take place through the lymph channels; or 
it may be secondary to a general pneumococcus septicemia. Peritonitis 
is infrequently due to infection through the female genital tract, espe- 
cially in gonococcus vulvovaginitis in older girls. Extension of inflam- 
mation from the male genital organs is very rare. In one case at the 
Xew York Infant Asylum, fatal peritonitis in an infant started from 
a suppurative inflammation of the tunica vaginalis of unknown origin, 
the infection extending into the peritoneum through the inguinal canal. 
Any abscess in the neighborhood may rupture into the peritoneum 
and excite peritonitis. Those most frequent in children are connected 
with Pott's disease, perinephritis, and cellulitis of the abdominal wall. 
It is occasionally seen in pyemia from any cause, and quite frequently 
occurs as one of the complications of septic sore throat. 

Of the acute infectious diseases, peritonitis is most frequently seen 
with pneumonia, and very rarely with scarlet fever. It is also seen as 
one of the complications of septic sore throat. When secondary to 
pneumonia, there is usually intense pleurisy and sometimes also peri- 
carditis and meningitis; in other words a general pneumococcus infec- 
tion is present. 

The bacteria most frequently associated with acute peritonitis in 
children are: the streptococcus, especially in the newly born; the pneu- 
mococcus in cases complicating pneumonia or empyema; and the strep- 
tococcus associated with the b. coli communis in those following intes- 
tinal perforation. 

Lesions. — In the fibrinous form there arc changes similar to those 
occurring in inflammation of the pleura and the other serous membra n 
The peritoneum is injected and fibrin is thrown out in considerabl 
quantity, usually accompanied by a small amount of serum. The process 
is usually a localized one. The peritoneum lining the abdominal wall. 
as well as that covering the adjaeent coils of intestine and the solid 
viscera, is covered by patches of yellowish-gray fibrin, causing adhesions 
between the various viscera and often matting the intestines together. 
In recent cases these adhesions are soft, and easily broken down; in old 
cases they are quite linn, and they may result in the formation of 
connective-tissue bands which are the source of subsequeni 1 rouble In 
16 



es. 
e 



440 DISEASES OF THE DIGESTIVE SYSTEM 

other cases the serum is more abundant, usually clear, but it may be 
turbid or even bloody. 

In the purulent form the products are serum, fibrin, and pus. When 
peritonitis results from perforation it is, as a rule, purulent from the 
outset, and the pus is foul and stinking. The amount of pus is pro- 
portionally larger than in adult cases. When the disease proves fatal 
in a few days there is found an extensive exudation of fibrin, with the 
formation of small pockets containing pus among the coils of intestine. 
Occasionally there may be larger collections of pus in the peritoneal 
cavity. In cases which have lasted a long time — generally those of 
localized inflammation — the process results in the formation of a peri- 
toneal abscess. This consists in a collection of pus in some part of the 
peritoneal cavity, the situation depending upon the cause, but it is 
usually in one iliac fossa or in the pelvis. The abscess is shut off from 
the rest of the peritoneal cavity by a thick wall of fibrin. If left alone, 
such abscesses may open into the rectum, vagina, bladder, pelvis of the 
kidney, or externally — usually at the umbilicus. After the discharge of 
pus the cavity may contract and fill up by granulation, and the patient 
recover. 

Inflammations of the other serous membranes, especially the pleura, 
are often associated with peritonitis. 

Symptoms. — The symptoms of acute peritonitis in older children, as 
in adults, are usually well marked and sufficiently characteristic to enable 
one to recognize the disease easily; but not so in the case of infants. In 
them the symptoms are often obscure, and the disease may be found at 
autopsy when not suspected during life. The onset is nearly always 
abrupt, with fever and vomiting. As a rule, the temperature is high — 
from 103° to 105° F. Vomiting may occur only at the onset, but it 
often continues; the vomited matters are usually green. Older children 
complain of pain, which may be localized or general, and in younger 
ones this is indicated by crying and fretfulness. The abdomen very soon 
becomes swollen and tympanitic, this being one of the most constant 
features of the disease. The distention is generally uniform, but it may 
be irregular. There is tenderness on pressure, and usually marked rigid- 
ity of the abdominal walls. The pain causes the child to assume a fixed 
position and he cries if moved or disturbed. The posture is generally 
dorsal, with the thighs flexed. The bowels are in most cases constipated, 
hit I, diarrhea is by no means rare. The abdominal distention causes 
dyspnea and thoracic breathing. There may be retention of urine or 
frequent micturition. 

The general symptoms, almost from the beginning, are those of a 
serious, disease. The pulse is small, rapid, and compressible. The 
prostration is great, from the very outset. The face is pinched, the 



ACUTE PERITONITIS 447 

mouth is drawn, and the features indicate pain. In severe eases there 
may be hiccough, cold extremities, clammy perspiration, and collapse. 
The mind is usually clear. In infants there may be convulsions. A 
polymorphonuclear leucocytosis is almost invariably present, but Is 
wanting in some cases of the gravest type. 

In the most severe forms of general peritonitis the course is shorl 
and intense, and the disease goes on rapidly from bad to worse until 
death occurs. In infants this is often on the third or fourth day. The 
very severe forms of general peritonitis in older children run the same 
rapid course. In other cases the course is slower, lasting a week or ten 
days. If the patient lives longer than this the case is more hopeful, 
because the process is more apt to be localized. The development of 
peritoneal abscess is indicated by the continuance of the temperature, 
which may assume a hectic type, and be accompanied by chills and 
sweating. There are the local signs of an abdominal tumor. 

Prognosis. — Acute general peritonitis, whatever its cause, is a very 
serious disease in childhood. Of eighty cases of all varieties under 
sixteen years of age, sixty-nine per cent were fatal. In the newly born 
and in infancy the disease is almost invariably fatal. In older children 
the outlook is not quite so hopeless, and depends upon the exciting 
cause. 

Treatment. — The medical treatment of acute general peritonitis in 
children is extremely unsatisfactory, as the disease is almost always fatal 
unless it can be relieved surgically. Opium is indicated only for the re- 
lief of the single symptom, pain. It has, however, serious disadvantages 
in that it may mask important symptoms. Other medical treatment is 
symptomatic only and is to be employed in conjunction with surgical 
measures. 

As a local application cold is usually to be preferred. II may be 
applied either by an ice-bag or by a Leiter's coil. It' children rebel 
againsl the use of cold, heat may he substituted. Turpentine stupes may 
aid in relieving tympanites. 

Feeding is always a difficult matter on account of Hie strong tend 
ency to vomit; this is due <<> regurgitation Prom Hie intestine ilito 
the stomach, which in some eases is almost continuous. In such con 
ditions greai benefit maybe obtained from washing the Btomach short] 
before feeding, repeating tins several times each daw In this way vomit- 
ing may often he controlled and the stomach made ready for food. The 
diet: should be milk, broth, or buttermilk. 

In every case of acute peritonitis an immediate exploratory operation 
should be done if the child's general condition will permit Appendicitis 
is often found to he the cause when least expected; and even when the 
peritonitis is due to some other cause operation gives the onlj chance 



448 DISEASES OF THE DIGESTIVE SYSTEM 

for recovery. Operation is also indicated in localized inflammations with 
the formation of peritoneal abscesses. 



CHRONIC (NON-TUBERCULOUS) PERITONITIS 

Peritonitis may occur in fetal life with the production of extensive 
adhesions, which may interfere with the development of the intestine and 
result in various malformations. These cases have been ascribed by 
Silbermann to syphilis. 

Chronic peritonitis may follow the acute form, in which there are 
left adhesions which slowly increase owing to the production of new 
connective tissue. Such cases are sometimes chronic from the be- 
ginning. 

The peritoneal abscesses which follow the suppurative form may 
run a chronic course. Chronic localized peritonitis may occur in con- 
nection with disease of any of the organs covered by the peritoneum. 

Chronic Peritonitis with Ascites. — In most cases this is chronic from 
the outset and independent of the causes above mentioned. By far the 
most frequent form of inflammation is that due to tuberculosis, and by 
some writers the opinion is still held that chronic peritonitis with ascites 
is always tuberculous. After the observations reported by Henoch, Vier- 
ordt, Fiedler, and others, there seems to be little room for doubting 
the existence of a chronic non-tuberculous form of peritonitis witri 
ascites, although it must be considered a rare disease. 

Etiology. — Nearly all the cases thus far reported have occurred 
in children over six years old. The causes are for the most part ob- 
scure. Chronic peritonitis may be associated with disease of the intes- 
tines or the solid viscera of the abdomen, especially with new growths 
of the kidney, liver, etc. 

Lesions. — The post-mortem observations thus far have been few. In 
the reported cases there has been found a large amount of greenish 
serum in the general peritoneal cavity, with a very moderate amount of 
fibrin and with adhesions, which are sometimes few and sometimes very 
numerous. Chronic pleurisy may be associated. 

Symptoms. — The early symptoms are of a very indefinite character, 
but often nothing whatever is noticed until the swelling of the abdomen 
begins. The enlargement comes on rather gradually in the course of a 
few weeks. Pain is slight, or wanting altogether. There may be some 
abdominal tenderness. The abdomen is usually distended with fluid. 
The general symptoms are very few. In some cases there is a slight 
evening rise of temperature of one or two degrees. There may be gen- 
eral weakness, loss of appetite, and moderate anemia. 



TUBERCULOUS PERITONITIS 449 

The usual course of the disease is for the fluid to remain for a 
time and then undergo slow absorption. In some instances there is no 
tendency to absorption of the fluid, the general health is gradually un- 
dermined, and the patients die from exhaustion or from some inter- 
current disease. The diagnosis rests upon the presence of ascites, devel- 
oping gradually without any signs or symptoms of disease in the heart, 
liver, or other organs. The points which distinguish it from tuberculous 
peritonitis are considered under that disease. The prognosis must be 
guarded on account of the difficulty in making a positive diagnosis from 
the tuberculous form. 

Treatment. — The treatment is entirely symptomatic. The patient 
should be kept at rest, preferably confined to bed. When there is no 
tendency to absorption, and especially when the patient's general 
health begins to suffer, the fluid should be removed by paracentesis. If 
it continues to accumulate after repeated tapping, laparotomy may 
be performed, for in some cases this has the same beneficial effect as in 
tuberculous peritonitis. 



TUBERCULOUS PERITONITIS 

The peritoneum is quite frequently the seat of tuberculous inflam- 
mation in early life. It occurs especially between the ages of one and 
five years, but is infrequent during the first year. Of 100 cases observed 
by Still, the largest number were seen in the second year of life. In 
255 autopsies upon tuberculous patients, most of them under three years 
old, of which we have records, the peritoneum was involved in 8.6 per 
cent; but in a majority of these the peritonitis was not the most impor- 
tant lesion nor the cause of death. Tuberculous peritonitis is apparently 
much more frequent in Europe than in this country. Thus, Still slates 
that this was the cause of death in 16.8 per cent of his tuberculous 
patients under twelve years of age, and in 12 per cent of the deaths 
from tuberculosis under two years. In 105 autopsies, for the most pari 
upon older tuberculous children, Ashby found the peritoneum involved 
in 36 per cent. In 883 collected autopsies upon tuberculous children of 
all ages, Biedert found the peritoneum involved in 18.3 per cent. These 
figures do not represent the number of cases of tuberculous peritonitis, 
as in many of them only a few miliary tubercles were present. 

It is possible for peritonitis to occur as the primary lesion of tuber- 
culosis, the bacilli entering by way of the intestine, causing do lesion of 
the mucous membrane; but in the greai majority of cases 11 is secondary 
to tuberculosis of the intestine, the mesenteric glands, the pleura, or 
to that of more distant parts, such as the lungs, the bronchial glands, 



450 DISEASES OF THE DIGESTIVE SYSTEM 

etc. In a small number of cases there is a history of some local excit- 
ing cause, such as a fall or blow upon the abdomen. The bovine type 
of the tubercle bacillus is more frequently found in tuberculous peri- 
tonitis than in any other form of tuberculosis, possibly excepting cervical 
adenitis, which fact is strongly suggestive of milk as the source of 
infection. 

Tuberculous peritonitis is usually associated with other abdominal 
lesions — tuberculosis of the mesenteric glands, intestinal ulceration, etc. 
It is very rarely acute, but usually occurs as a, subacute or chronic- 
disease. 

The peritoneum may be involved as one of the lesions in acute or 
subacute general miliary tuberculosis. The lesions consist in a deposit 
of miliary tubercles, which are generally rather sparsely scattered over 
the peritoneum. The evidences of inflammation are very slight, or they 
may be absent altogether. These cases do not come under observation 
as cases of peritonitis, as there are no abdominal symptoms. 

The principal anatomical and clinical varieties of tuberculous peri- 
tonitis are the ascitic and the fibrous forms. 

The Ascitic Form. — This is much less frequent than the fibrous form. 
The peritoneum is thickly sown with miliary tubercles, both discrete 
and in conglomerate masses. They are found in the omentum and the 
mesentery, upon the surface of the intestines and the solid viscera. 
The peritoneum shows in varying degrees the changes of acute or sub- 
acute inflammation, with the production of a moderate amount of fibrin 
and a large amount of serum. In the most acute cases the fluid is 
in the general peritoneal cavity. In those of longer duration it may 
be sacculated. The fluid is usually abundant, but not excessive. It is 
most commonly a straw-colored serum, but it may be seropurulent, 
or even bloody. There are commonly other lesions of tuberculosis in 
the body, but they are usually less marked than those of the 
peritoneum. 

Clinically, ascitic cases usually present the symptoms of a low grade 
of peritoneal inflammation. The onset is gradual, with indefinite gen- 
eral symptoms. There is usually some fever — 100° to 101.5° F. There 
is general weakness, prostration, and some loss of flesh, but not rapid 
emaciation. Vomiting is not prominent, and pain and tenderness are 
often absent. There may be nothing distinctive until distention of the 
abdomen is seen. This at first is due to intestinal gas, but later to fluid, 
which may accumulate in sufficient quantity to fill the general peritoneal 
cavity. The bowels may bo constipated or there may be diarrhea. In 
other cases there may be only a slowly developing ascites without any 
inflammatory signs, and the abdominal enlargement is practically the 
only symptom. 



TUBERCULOUS PERITONITIS 451 

The ascitic form of tuberculous peritonitis may result fatally, death 
occurring from general tuberculosis or by slow exhaustion from the local 
disease; the duration under these conditions is usually from two to >ix 
months. At other times the fluid may gradually undergo absorption 
and recovery take place, or after absorption the fibrous form of inflam- 
mation may develop. 

The Fibrous Form. — This is generally slower in its development and 
more chronic in its course than the ascitic form. There is a tuberculous 
inflammation, the products of which have undergone transformation to a 
greater or less extent into fibrous tissue. The most important feature 
of these cases is the production of extensive organized adhesions be- 
tween the solid viscera and the intestines, between the intestinal coils, 
and between the intestines and the abdominal walls. The intestines may 
be compressed against the spine by bands. 

These adhesions and their mechanical consequences are sometimes 
almost the only lesions present. In other cases there may be an ac- 
cumulation of fluid, which may be sacculated or in the general peritoneal 
cavity. This may be serous, seropurulent, or purulent. The omentum 
may be greatly thickened. There are often present in the fibrous exu- 
date covering the intestines, in the omentum, and in the mesentery, 
tuberculous deposits consisting of caseous nodules or larger caseous 
masses, which are frequently softened at the center. Tuberculous 
deposits are found upon the peritoneal surface of the intestine, and 
infiltrate the intestinal walls, often leading to perforation, and some- 
times to fistulous communications between adherent intestinal coils. 
There may also be tuberculous infiltration of the abdominal walls, 
accompanied by cellulitis, resulting in abscesses, which may open ex- 
ternally, usually in the neighborhood of the umbilicus. 

Clinically, these cases are distinguished by their slow, irregular 
course. They are the most chronic of all the forms. The onset i> 
generally insidious, and fever is commonly absent. 'There is rarely 
vomiting. The bowels may be constipated or loose. For a long time 
the general health may remain good. The only characteristic symptom 
is the enlargement of the abdomen. In the early pari of the disease this 
is chiefly from the tympanites, but later there may be some accumulation 
of fluid. It is rare that the inflammation remains entirely fibrinous. 
Ascites usually develops very slowly, but may be abundant. The adhe- 
sions of the intestines may give pise to irregularities in the outline of 
the abdomen. Ascites may be present for a time and then disappear 
spontaneously, and the general health may bo improve that the patient 
is considered quite well. There may even be a permanenl cure. In 
other cases, after symptoms have been absent for some time, rela] 
occur, and more fluid is poured out. In addition to these symptoms, 



452 DISEASES OF THE DIGESTIVE SYSTEM 

others are present depending upon the mechanical effects of pressure 
from the contracting adhesions. There may be more or less constric- 
tion of the intestine, pressure upon the vena cava, the renal or portal 
veins, the thoracic duct or its branches, or upon the stomach. These 
conditions may give rise to dyspeptic symptoms, emaciation,, edema of 
the lower extremities, and albuminuria. In some cases tuberculous 
peritonitis is entirely latent, and it is discovered at autopsy when there 
have been either no abdominal symptoms during life, or only colicky 
pains of an indefinite character. The course of this form of peritonitis 
is slow and irregular; it generally lasts for from six to twelve months, 
although with intermissions and exacerbations it may extend over 
several years. 

If softening and breaking down of inflammatory products take place, 
well-marked constitutional symptoms are usually present. These are 
partly from the peritonitis and partly from general tuberculosis. Fever 
is regularly present, the temperature usually ranging from 99° to 
102° F., though it is occasionally much higher. There is progressive 
emaciation, anemia, prostration, and sweating. Diarrhea is frequent 
and the intestinal discharges may at times be bloody. The abdomen is 
large, but not so much distended as in some of the other forms; the 
superficial veins are frequently prominent. Ascites often can not be 
made out by percussion, even though fluid is present. Areas of dulness 
and tympanitic resonance are irregularly distributed. Nodular masses 
of various sizes and irregular shapes may be felt anywhere in the abdo- 
men, but they are more frequently in the region of the umbilicus and in 
the right iliac fossa than elsewhere. The epigastric region may be 
occupied by a smooth, hard tumor — the thickened omentum — which 
may resemble the liver. There may be the signs of phlegmonous inflam- 
mation of the abdominal wall in the neighborhood of the umbilicus, 
and even an abscess, which, after opening, may leave a fistulous com- 
munication with the peritoneum. There are usually some signs of dis- 
ease in the lungs, and the pulmonary symptoms may mask those of the 
abdomen. The course of the disease, when softening and breaking down 
have taken place, is steadily progressive, the usual duration being from 
three to six months. Death results from the pulmonary disease, from 
tuberculous meningitis, from exhaustion, and occasionally it is due to 
accidents associated with perforation. 

Diagnosis. — The essential symptoms of tuberculous peritonitis are an 
enlarged abdomen, often with evidence of fluid, wasting, colicky pains, 
irregularity of the bowels, nodular masses in the abdomen, and usually 
slight but continuous fever. In young children chronic ascites with 
fever usually means tuberculous peritonitis. Pouting of the navel, with 
induration and redness about it, is suggestive, and any chronic abscess 



TUBERCULOUS PERITONITIS 453 

in the neighborhood of the umbilicus is suspicious. If the abdominal 
effusion is sacculated instead of diffuse, the probabilities of peritonitis 
are much increased. If there are added physical signs pointing to dis- 
ease of the lungs or the evidence of tuberculosis elsewhere, and a positive 
cutaneous tuberculin reaction, the diagnosis is almost certain. Cirrhosis 
of the liver is practically unknown in infancy and early childhood. 
When ascites is absent, tuberculosis of the peritoneum may be suspected 
if there are irregular nodules or masses in various parts of the abdomen, 
with tenderness, emaciation, colicky pains, and, in the later stages, 
fever. But fever may be absent for a long time, even though local 
symptoms are marked. The epigastric tumor due to omental thickening 
may be mistaken for the liver; but it generally extends quite across the 
abdomen, and the upper as well as lower border can often be felt. 
Fecal masses may resemble tuberculous deposits, but are removed by 
cathartics and enemata. 

Abdominal paracentesis to establish the presence of fluid or to allow 
of its examination is not justifiable. The danger of injury to the 
intestines even when a considerable accumulation of fluid is present is 
too great. 

Prognosis. — Tuberculous peritonitis is always a serious disease, but 
by no means a hopeless one. The younger the child as a rule the more 
rapid the progress of the disease and the worse the outlook. The 
prognosis is especially bad during the first three years of life; at this 
period most of the cases terminate fatally. Many cases occurring in 
older children recover spontaneously and entirely. The most hopeful 
ones are those with ascites. But even in the fibrous form sonic appar- 
ently complete recoveries take place, the adhesions disappearing by 
absorption to a degree truly remarkable. The most unfavorable eases 
are those in which there is strong evidence of the breaking down of 
tuberculous deposits, with continuous fever and wasting. 

Treatment. — The general treatment of tuberculous peritonitis is sim- 
ilar to that of tuberculosis in other parts of the body. The essentials 
are, rest, which should be invariably in the recumbent position, a 
climate mild enough to permit the patient to remain out of doors the 
greater part of the time, and very careful attention to feeding, with the 
purpose of improving the general nutrition. Eeliotherapy, or the direct 
exposure of the abdomen to the sun'.- rays, has been much vaunted 
as a remedy and merits a trial as it can be employed in conjunction 
with the measures just mentioned. Beginning with a few minutes' 
exposure the time may he gradually lengthened to two or three hours. 
Under general treatment a very considerable number of patients re- 
cover, especially those who are over three years old. Such a termina- 
tion is more likely if the diagnosis bas •"■<'') made early and if the 



454 DISEASES OF THE DIGESTIVE SYSTEM 

disease is limited to the peritoneum. Drugs play but a small part in 
the treatment of these cases. The value of tuberculin in tuberculous 
peritonitis has not yet been established. 

In cases not progressing favorably under medical treatment, the 
question of operation should be considered. This was for a number 
of years a very frequent procedure and was employed in almost all 
cases. The results were not, however, such as to make it advisable 
as a routine measure. Hygienic treatment alone accomplishes in gen- 
eral as much if not more. In certain circumstances, operation is 
advisable. The most favorable cases are those of the ascitic variety. 
It may be useful also with localized or general suppuration and for 
the relief .of intestinal obstruction occurring in the course of the dis- 
ease. Operation affords temporary relief in some cases when the dis- 
tention is very great. In the fibrous form not much is to be expected 
from it. Operation may be done for the relief of recurring colicky 
pains due presumably to constriction by bands. The existence of other 
foci of tuberculosis does not contraindicate operation except when these 
are chiefly intestinal, or when there is advanced general tuberculosis. In 
deciding the question of operation, its unfavorable results should also be 
borne in mind. A not uncommon consequence is injury to the intestine 
from the breaking up of adhesions, which may result in fecal fistulae. 
For the surgical aspect of the treatment the reader should consult works 
upon surgery. 

ASCITES 

Ascites consists in an accumulation of fluid, usually clear serum, in 
the general peritoneal cavity. It is a symptom of the various forms of 
peritonitis, especially the chronic varieties described in the preceding 
pages. It may be due also to portal obstruction from cirrhosis of the 
liver, or pressure upon the portal vein by peritoneal adhesions or large 
lymphatic glands. It is occasionally seen in all forms of abdominal 
tumors. Ascites may occur in general dropsy from cardiac disease, 
or from any condition causing pressure upon the vena cava. It is also 
seen in the general dropsy of renal disease. A moderate amount of 
ascites is often met with in extreme anemia or leukemia. 

Small accumulations of fluid in the peritoneal cavity are difficult of 
detection. Large amounts are generally easily made out. There is a 
uniform smooth distention of the abdomen and dilatation of the super- 
ficial veins, especially about the umbilicus. On palpation, the wave of 
fluctuation can be obtained by placing one hand against the abdomen 
upon one side and giving the opposite side a sharp tap. A similar wave 
may be felt when there is tympanitic distention. The two are, however, 



SUBPHRENIC ABSCESS 455 

distinguished by having an assistant make pressure with the edge of 
the hand along the linea alba while the test is being made; this ob- 
structs the wave transmitted through the abdominal wall, but does not 
affect that through the fluid. On percussion in the sitting posture, 
there is dulness below and resonance above. When the patient is recum- 
bent, there is resonance in the median line and dulness or flatness in 
the lateral portion of the abdomen. 

The prognosis and treatment of ascites will depend upon its cause. 

Chylous Ascites. — This term is applied to certain cases in which the 
abdominal fluid contains fat. The color may be milky-white or light 
brown, and the fluid, after standing, may have at its surface a thick, 
creamy layer. The amount of fat present has been as high as five per 
cent. This condition is rare in childhood. The exact pathology is as 
yet not well understood. In the cases which have thus far come to 
autopsy there has usually been found chronic peritonitis, sometimes 
simple, sometimes tuberculous. The lymph vessels in some of the cases 
have been empty, and often no obstruction of the lymph circulation 
could be discovered. The fat is believed by some to be derived from 
fatty degeneration of the products of chronic inflammation, but this 
seems hardly sufficient to explain the large amount of fat sometimes 
found. In some of the cases it has been due to a wound of the thoracic 
duct. The amount of fluid is frequently very large. The prognosis is 
usually bad, although Pounds has reported a case in a girl of ten years, 
where recovery followed laparotomy. Tuberculous peritonitis was 
present. 

SUBPHRENIC ABSCESS 

In the group of cases of localized peritonitis or peritoneal abscess, 
must be included subphrenic abscess. This is a rare condition in child- 
hood, and consists in an accumulation of pus just beneath the diaphragm 
and above the liver. lis cause may be either in the thorax or in the ;il>- 
domen. It may complicate acute pneumonia, usually of the righi lower 
lobe, by ;i direct extension of infection through the lymph channels. 
Sometimi it hai been associated with phthisical cavities* In the abdo- 
men it results from the extension of some Incus of suppuration, such 
.1 .in abscess around the appendix or abscess of the liver. The accumu 
lation of pus is sometimes very great, so that the diaphragm 1- crowded 
high into the thorax. 

The symptoms and physical signs closely resemble those of empyema, 
and most of the cases have been operated upon with the belief thai (he 
surgeon was dealing with empyema. Meltzer has reported a case in a 
child of two years which followed pneumonia of the righi base. Ai the 



456 DISEASES OF THE DIGESTIVE SYSTEM 

operation only a few drops of pus were found in the pleural cavity; but 
there was discovered a pinhole opening in the diaphragm, from which 
the pus had escaped, and a large subphrenic abscess. This was evacu- 
ated, and the patient recovered perfectly. Subphrenic abscesses may 
contain air; they are then likely to be mistaken for pneumothorax. 
These abscesses require incision and drainage like other forms of peri- 
toneal abscess. 



SECTION IV 
DISEASES OF THE RESPIRATORY SYSTEM 

CHAPTER I 
NASAL CAVITIES 

ACUTE RHINOPHARYNGITIS 

(Acute Nasal Catarrh — Coryza) 

Although the symptoms of acute nasal catarrh are chiefly nasal, 
the principal seat of the pathological process is the rhinopharynx. 

Etiology. — Certain children are predisposed to attacks of acute nasal 
catarrh. This predisposition, as it sometimes extends to entire fam- 
ilies, may be inherited; but more frequently it is acquired, and usually 
by the following mode of life : It is seen in children who get very little 
fresh air, because they are kept indoors unless the weather is perfect; 
who live in houses always overheated; whose sleeping rooms are kept 
carefully closed at night for fear they may take cold; who are for the 
same reason so overloaded with clothing that they can not engage in 
any active play without being thrown into a profuse perspiration. These 
conditions after a time result in a great sensitiveness of all the mucous 
membranes, but especially those of the nose and pharynx, which is much 
increased by residence in a damp, changeable climate. Young infants 
and those who are rachitic, are frequent sufferers from acute nasi I 
catarrh. Attacks are often brought on by insufficienl covering for the 
head, by wetting the feet, by cold and exposure, especially to street dust 
and the raw winds of winter and spring, accompanied by the damp- 
ness which occurs with melting snow. In susceptible children the ex- 
citing cause is often a very trivial one. A draughl of cold air for a 
few minutes may be sufficient to excite sneezing and a nasal dischai 
Atmospheric conditions are probably not I la 1 only cause of acute aasal 
catarrh. Microorganisms certainly play an important pan. The 
staphylococcus, streptococcus and pneumococcus arc commonly found 
associated with this condition, much less frequently the influenza bacillus. 

457 



458 DISEASES OF THE RESPIRATORY SYSTEM 

Eecent observations of Tunnicliff showed the presence of a new organism 
called the "bacillus rhinitis" in 98 per cent of the cases of acute rhinitis 
studied and in 66 per cent it was the only organism present. It is a 
Gram-negative anaerobic bacillus. Acute catarrh may be sporadic or 
epidemic; certain forms are contagious, being communicated by children 
using the same handkerchief, occupying the same bed or simply by 
close contact. 

Acute nasal catarrh may be a symptom of measles, nasal, diphtheria, 
or influenza, and it may accompany erysipelas of the face. 

Symptoms.— In the mild form the changes in the mucous membrane 
of the nose are not great, and are usually secondary to those of the 
rhinopharynx, being in a large measure due to the discharge. There is 
redness and slight swelling. The nasal passages may be for the time 
quite occluded by the discharge, which is usually profuse, at first sero- 
mucous, and later mucopurulent. The symptoms may be very transient, 
sometimes passing away in a few hours, in which case there is only a 
vasomotor disturbance; or they may continue and develop into a true 
inflammation. The discharge may excoriate the nostrils and the upper 
lip. At the onset there is usually sneezing, and in infants often a slight 
fever. 

In older children there is no rise of temperature except in the 
most severe cases. The obstruction to nasal respiration causes mouth- 
breathing, and the dryness and discomfort which result from it produce 
disturbed sleep, snuffling and difficulty in nursing, this being in severe 
cases almost impossible. The inflammation may extend to the lachrymal 
duct, involving the eyes in a mild conjunctivitis. The process often 
extends to the larynx and bronchi, with hoarseness and cough. There 
may be closure of the Eustachian tubes, causing deafness and otalgia. 
The chief complication for which, the physician should watch is otitis. 

The severe form in infants is often attended by marked constitutional 
symptoms; the temperature may be as high as 101° or 105° F. and some- 
times fluctuates widely. The discharge soon becomes mucopurulent and 
is very profuse, pouring from the anterior nares and filling the pharynx. 
The cultures in this form frequently show the pneumococcus. Severe 
symptoms often continue for a week or more, the child being seriously 
ill. Complications are almost always present. In most cases there is 
cervical adenitis and otitis. If the child is a delicate one bronchopneu- 
monia is apt to develop. Eetropharyngeal abscess is not infrequently 
seen. 

Diagnosis. — It is important to distinguish between a simple acute 
catarrh and one due to measles, influenza, nasal diphtheria, or hereditary 
syphilis. Measles and influenza usually cause more fever and general 
constitutional disturbance than does simple catarrh. Nasal diphtheria 



ACUTE RHINOPHARYNGITIS 459 

may be present when there is only a profuse discharge tinged with blood. 
When such a discharge persists for two or three weeks this is always to 
be suspected, even though the constitutional symptoms may be very 
slight. The only positive means of excluding diphtheria is by cultures. 
A persistent acute nasal catarrh in a young infant should always sug- 
gest syphilis, and the patient should be carefully watched for the de- 
velopment of other symptoms. 

Treatment. — A young child suffering from acute coryza should be 
kept indoors in a room with an even temperature of about 70° F., the 
bowels freely opened, and the amount of food somewhat reduced. The 
only drug which seems to have much influence upon the secretion is 
belladonna. 

Useful local applications are liquid albolene, oleostearate of zinc, or 
alkaline sprays, such as Seller's solution, to clear away the secretions. 
If the nasal obstruction causes great interference with respiration or 
nursing, epinephrin diluted with a saline solution may be used with ;i 
medicine dropper. 

The upper lip and nostrils should be protected by vaseline or sonic 
simple ointment. Under no circumstances should irritating or astrin- 
gent injections be given. In older children inhalations of spirits of 
camphor may be used with some advantage. 

The severe cases require more active treatment. For most of them 
nasal irrigation with a warm saline solution is to be advised. This 
should be done as in diphtheria. After cleansing the rhinopharvnx a 
few drops of a five-per-cent solution of argyrol may be dropped into the 
nostrils two or three times daily. 

Prophylaxis consists in solving the perplexing question, so often 
put to the physician, of how to prevent children from ''inking cold." 
This is a matter of the utmost importance, and follows what has been 
previously said under the head of Etiology. Xo amount of cod-liver oil 
and iron will remove this tendency to catarrh so long as had hygienic 
conditions continue. Sleeping rooms should he large and well ventilated. 
and a window should he kept open ai night, except in very severe weather 
or during acute attacks. The temperature of the house during the day 
should be kept from 65° to 68° F.. I>ut not above this. Children Bhould 
be accustomed to go out of doors unless the weather i- especially bad. 
So firmly rooted in the mind- of the laity is the idea that acute catarrhs 
come from cold, that the habit of coddling delicate children is always 
likely to be carried to an extreme. 

With every delicate and "catarrhal" child one should begin in the 
summer by having him live in the open air as much a- possible, sli 
ing in a room with free ventilation, with moderate covering, and con- 
tinuing the same practice int.. the fall and early winter. If begun 



460 DISEASES OF THE RESPIRATOKY SYSTEM 

gradually in this way there is little difficulty in continuing throughout 
the winter. 

The next point to be insisted on is cold sponging immediately upon 
rising in the morning, especially about the chest, throat, and spine. The 
use of cnest protectors, cotton pads, and extremely thick clothing should 
be prohibited. Woolen underclothing should be worn upon the chest 
throughout the year, and upon the legs also in winter ; the very lightest 
in summer, and only a medium weight in winter. 

Frequently repeated attacks point to the presence of adenoid vegeta- 
tions in the pharynx, and no measures are of much avail until these 
are removed. 

CHRONIC NASAL CATARRH 

This term is rather loosely used to designate a chronic nasal dis- 
charge. Such a discharge is common both in infancy and childhood. 
It is a condition frequently neglected by physicians. Patients are too 
often subjected to routine constitutional treatment by cod-liver oil and 
preparations of iodin, with the idea that such cases are "scrofulous," 
while local treatment is either neglected altogether, or consists only of 
the use of the nasal douche or syringing with a saline solution. Perma- 
nent damage to the organs of hearing, smell, speech, and respiration may 
result from neglecting or ignoring chronic nasal catarrh in childhood. 

Chronic nasal catarrh is not to be regarded as a disease, but only as 
a symptom which may be due to any one of a variety of pathological 
conditions, each of which requires very different treatment, viz., adenoid 
growths of the pharynx, foreign bodies in the nose, polypi, deviation 
of the septum or any other congenital deformity of the nasal passages, 
the various forms of chronic rhinitis, and syphilis, which causes a form 
of rhinitis peculiar to itself. 

Adenoid Growths of the Pharynx. — These are more fully discussed 
elsewhere. They are by far the most frequent cause of chronic nasal 
discharge in infants and young children, and should be first sus- 
pected. The nasal discharge accompanying adenoid growths is due to 
a chronic rhinopharyngitis. Treatment is without avail unless the 
growths are removed. After this is done the nasal discharge usually 
disappears quite promptly. 

Foreign Bodies in the Nose. — This condition should be suspected 
whenever there is an abundant mucopurulent discharge limited to one 
nostril. Foreign bodies in the nose are quite frequent in young children. 
Peas, beans, beads, or shoe buttons are most frequently lodged there. 
The efforts at removal on the part of the child, or the parents, gen- 
erally result in pushing the body farther into the nose, It first sets 



CHRONIC RHINITIS 461 

up a mechanical irritation, accompanied by pain, swelling, sneezing, and 
sometimes hemorrhage. This is followed by a catarrhal inflammation 
which in the course of a few days becomes purulent and may last in- 
definitely. The discharge is generally quite abundant. The symptoms 
point to an obstruction of one nostril, and an examination with a probe 
readily detects the presence of the foreign body. 

In recent cases the removal of the foreign body may sometimes be 
accomplished by compressing the empty nostril and having the child 
blow his nose strongly. Often the sneezing which the foreign bodv ex- 
cites is sufficient to remove it. Before any attempt is made to seize the 
body with forceps, cocain should be used, not only for the purpose of 
preventing pain, but in order to contract the mucous membrane so as to 
allow better manipulation. In many cases general anesthesia is neces- 
sary. In most circumstances ordinary foreign bodies can with proper 
forceps be extracted without difficulty. No subsequent treatment is re- 
quired, except the use of some mild antiseptic to keep the nose clean for 
a few days, as the inflammation quickly subsides after the removal of 
the cause. 

Nasal Polypi. — These are among the infrequent causes of chronic 
nasal discharge in childhood. They are especially rare before the seventh 
year, but both mucous and fibrous polypi are seen. The symptoms are 
those of a chronic nasal catarrh with partial or complete obstruction of 
one or both sides. Polypi increase in size with the occurrence of every 
acute coryza, and are always especially troublesome in damp weather. 
They may be accompanied by reflex symptoms, such as cough, sneezing, 
and even by attacks of asthma. There may be headache, and sometimes 
disturbances of smell, taste, and hearing. The symptoms are of much 
longer duration than in the case of obstruction from a foreign body, the 
discharge is not so abundant, and is not purulent. The diagnosis is 
made only by local examination. 

Polypi may be removed with the forceps, but this is best accomplished 
by the use of the wire snare. When they have been present for a l"iiu r 
time the accompanying chronic rhinitis may require subsequent 
treatment. 

Deviation of the nasal septum, and other congenital deformities 
which may cause narrowing of the nasal respiratory tract, arc conditions 
which belong to the specialist. 



CHRONIC RHINITIS 

Simple Chronic Rhinitis. — Simple chronic rhinitis existing alone is 

of rare occurrence in young children. Tn the i i lassed the symp- 



462 DISEASES OF THE RESPIRATORY SYSTEM 

toms are usually due to rhinopharyngitis, which almost invariably de- 
pends upon adenoid growths. The growth may be a small one, so that 
the symptoms of obstruction are slight or absent. A frequent com- 
plication is chronic enlargement of the cervical lymph nodes. 

The only constant symptom is an excessive nasal discharge which is 
usually mucous but which may be mucopurulent. It is easily removed 
by blowing the nose if the child is old enough to be taught to do this. 
Children too young to clear the nose in this way suffer from almost con- 
stant discomfort. The amount of discharge depends upon the severity of 
the case. It frequently causes irritation of the upper lip, which may be 
the seat of eczema or impetigo, especially in infants. The lip may be 
swollen and prominent. The condition of the external parts is aggra- 
vated by the constant disposition to pick the nose, which may be over- 
come by the application of a short anterior splint to each elbow. 

Epistaxis sometimes occurs. The duration of the disease is indefi- 
nite ; it may last for months or even for years, the symptoms in summer 
being insignificant, but returning every cold season. It may terminate 
in recovery, or, in children with flabby tissues and delicate constitution, 
it may be followed in later childhood by hypertrophic rhinitis. 

Treatment. — Proph}daxis is important. The main purpose should 
be to prevent attacks of acute nasal catarrh by the measures mentioned 
in the discussion of that disease. The general treatment should not be 
routine, but based upon the indications of each case. General tonic 
treatment is required in most cases. 

Local treatment consists first in cleanliness, and, secondly, in the use 
of astringents. In infants, if the discharge is abundant, an efficient 
method of getting rid of it is by nasal syringing. This is attended 
by some risk of forcing materials into the middle ear; but if very care- 
fully done, the danger seems to be less than that of allowing the dis- 
charge to remain. All solutions are to be made with sterile water and 
used warm, either with a nasal douche or syringe. No force should 
be employed. Either Dobell's or Seller's solution may be employed, 
diluted with an equal amount of water. Eecently there have been intro- 
duced several devices for removing abundant secretion b} r means of 
suction, which obviate the risks attendant upon the syringe and are 
even more efficient. Ordinarily, the nose should be cleansed thoroughly 
twice a day, more frequently in very severe cases. Harm is often done 
by the overzealous use of local treatment in these conditions. 

Syphilitic Rhinitis. — Ehinitis is seen both in early and late hered- 
itary syphilis. Corvza. or snuffles, is one of its earliest and most con- 
stant symptoms. It usually begins between the third and sixth weeks 
of life, rarely after the third month. The pathological condition is a 
subacute catarrhal rhinitis, sometimes with the formation of superficial 



EPISTAXLS 463 

ulcers or mucous patches. The disease is usually attended by a profuse 
nasal discharge of seromucus or mucopus, occasionally tinged with blood. 
It may continue from a few weeks to two or three months. It usually 
requires only constitutional treatment and protection of the nostrils 
and lips by the use of the ointment of the yellow oxid of mercury 
diluted with four parts of vaseline. When the discharge is very abun- 
dant any one of the cleansing solutions previously mentioned may be 
used as a spray. 

The rhinitis of late hereditary syphilis is a very different patholog- 
ical condition. There are here gummatous deposits which break down, 
and form ulcers of the mucous membrane and deeper tissues. There is 
also periostitis, with extension of the disease to the cartilages and bones 
of the nasal fossae, particularly of the septum. There may be perfora- 
tion of the triangular cartilage, necrosis of the vomer or nasal bones, 
perforation of the hard or soft palate, and at times extensive ulceration 
of the alae nasi and the face. Cicatrization may follow, causing stenosis 
of the nostril. These lesions in the nose are generally accompanied by 
deep ulceration of the pharynx and soft palate. They usually occur in 
children who have presented the early symptoms of hereditary syphilis, 
but are occasionally seen when no such history can be obtained. Such 
was the case in a patient recently under observation in the Babies* Hos- 
pital, who had perforation of the nasal septum and of the floor of the 
nasal fossae, causing a free communication with the mouth. These are 
cases of true ozena. The odor from the discharge is at times almosl 
intolerable. When neglected these cases go on from bad to worse 
and may continue for years, producing unsightly deformities. 

The constitutional treatment is that of hereditary syphilis in gen- 
eral and is discussed in the chapter upon that disease. 

Locally there may be used a spray of one of the cleansing solutions 
already mentioned, or black wash, or a solution of bichlorid of mercury, 
1 to 10,000. Although improvement may take place quite promptly, the 
results of treatment in the late cases are often unsatisfactory, as the 
disease has usually progressed so far before treatmenl Is begun thai 
some deformity of the nose results, usually a sinking in of the bridge 
and flattening of the alae, giving rise to the so-called "saddle-hack" 
deformity. 

EPISTAXIS 

The hemorrhage may come from any part of the nasal fossae, but it 
is generally from the anterior nares, and mosl frequently from the 
sels of tin septum. Epistaxis is a rare symptom in the hemorrhages of 
the newly born, and when presenl suggests syphilis. It is infrequent 



464 DISEASES OF THE RESPIRATORY SYSTEM 

throughout infancy, but in childhood it is quite common, occurring in 
boys more frequently than in girls. In the latter it is especially common 
about the time of puberty. Children who are kept much indoors in 
overheated apartments, and who have susceptible mucous membranes and 
flabby tissues, are particularly prone to it. The exciting cause may be a 
local one, like a fall or blow; epistaxis may be due to picking the nose, 
or to any kind of mechanical irritation ; it may be associated with nasal 
catarrh; and it is often caused by a small ulcer upon the septum. An 
attack may be brought on by mental or physical excitement. It occurs 
as an occasional, often an early symptom, in typhoid or malarial fever, 
in measles, or during severe paroxysms of pertussis. It is seen in the 
hemorrhagic form of all the eruptive fevers, in certain cases of diph- 
theria, in hemophilia and scorbutus, in grave anemia, leukemia, and in 
diseases of the heart and blood vessels. 

Symptoms. — Epistaxis is frequently preceded by a sense of fulness or 
pain in the head, which is relieved by the bleeding. The blood is usually 
from one nostril, and comes slowly by drops. The amount lost is gen- 
erally small, but it may be large enough, when repeated, to produce a 
serious grade of anemia even in strong children; the hemorrhage may 
even prove fatal. Epistaxis may be overlooked if the blood finds its 
way into the pharynx and is swallowed. In most of the cases the hemor- 
rhage ceases spontaneously in from ten to twenty minutes, recurring at 
longer or shorter intervals, according to the nature of the cause. Hem- 
orrhage from adenoid growths of the pharynx may closely resemble that 
from the nose, but otherwise there can rarely be any difficulty in recog- 
nizing epistaxis. 

Prognosis. — This depends upon the cause. In the great majority of 
the so-called idiopathic cases epistaxis is not serious. Occurring early in 
the course of one of the infectious diseases, it does not ordinarily affect 
the prognosis unless it is very severe. When it occurs late, however, it 
is always a bad sign, and particularly so in diphtheria. It may be 
serious in any of the hemorrhagic diseases or in diseases of the blood, 
when it is not infrequently a cause of death. 

Treatment. — To remove the predisposition, a child should receive 
general tonic treatment, especially plenty of outdoor exercise, and every 
means should be taken, by the use of cold baths, friction, and proper 
food, to tone up the vascular system. 

An efficient means of arresting the hemorrhage is compression of the 
nose between the thumb and finger. This may be combined with the 
application of ice over the nose, and sometimes small pieces of ice may 
be introduced into the nostrils. The application of cold to the back of 
the neck or its use in the mouth may be of service by exciting reflex 
contraction of the capillary vessels. All tight clothing or bands about 



CATARRHAL SPASM OF THE LARYNX 465 

the neck should be loosened, and the patient kept quiet in the sitting 
posture. After the hemorrhage has ceased the child should not blow 
his nose for some time. Epinephrin is one of the most efficient local 
means of checking the bleeding. Another valuable remedy is the peroxid 
of hydrogen, used full strength. If bleeding continues in spite of all 
the above measures, the anterior nares should be plugged, and if this 
does not control it, the posterior nares should be plugged. Usually very 
little effect is seen from drugs given internally, although in frequently 
recurring hemorrhages where no local cause can be discovered, calcium 
lactate should be tried ; from thirty to sixty grains a day should be given 
to a child of five years. 

The subcutaneous use of horse serum often has a very decided effect 
in controlling these hemorrhages which do not yield readily to the usual 
treatment. From 20 to 30 c.c. may be given to a child of five years and 
repeated every few hours if bleeding continues. Human serum is even 
more efficacious. In very severe hemorrhages transfusion may be neces- 
sary. In severe cases of nasal hemorrhage recurring at short intervals 
without any apparent cause, ulcer of the septum should be suspected, 
and, if present, should be touched with chromic acid. 



CHAPTER II 

DISEASES OF THE LARYNX 

The characteristic feature of laryngeal disease in infants and young 
children is the association of muscular spasm with every form of inflam- 
mation. Often it is the laryngeal spasm, rather than the inflamma- 
tion, which gives rise to the principal symptoms. This spasm is only one 
expression of the great reflex irritability of young children. 

CATARRHAL SPASM OF THE LARYNX 

(Spasmodic Laryngitis; Spasmodic Croup; Catarrhal Croup) 

The term catarrhal spasm is fairly descriptive of this disease, which 
is characterized by a very mild degree of catarrhal i n flammation asso- 
ciated with marked laryngeal spasm. 

Etiology.— It is not often .-ecu during the first BO month-, hut is 
frequent from this time up to the third year. After fiv< is rare. 

It occurs rather oftener in children who aro well nourished. ( lertain chil- 



466 DISEASES OF THE RESPIRATORY SYSTEM 

dren have a predisposition to such attacks, those who have had one attack 
are likely to have others. The condition has many points of resemblance 
to spasmodic asthma which may replace it in later childhood. Heredity 
seems to have some influence in producing this extreme susceptibility of 
the air passages. Catarrhal spasm of the larynx is very frequently asso- 
ciated with enlarged tonsils and adenoid growths of the pharynx, some- 
times with an elongated uvula. The exciting cause may be exposure to 
cold, especially to high winds, or an attack of indigestion. There is no 
doubt that catarrhal spasm of the larynx is seen at the present time 
much less frequently than formerly; the reason for this is not clear. 

Lesions. — The catarrhal inflammation of the larynx affects chiefly 
the parts above the cords; there is congestion and dryness, and later 
increased secretion of mucus. To this there is added a spasm of the 
muscles of the larynx. There is no submucous infiltration, and no 
tendency to edema of the glottis. 

Symptoms. — The attack may be preceded for several hours by slight 
hoarseness, or by a nasal discharge. During the day the child may 
appear perfectly well. Usually there is heard during the evening a 
hollow, barking cough, at first infrequent and not severe. About mid- 
night this is apt to increase in severity, and there is now difficulty in 
breathing. As soon as this becomes marked the child wakes, and presents 
the characteristic symptoms of an attack. In the mild cases the dyspnea 
is not sufficient to waken the child. In severe cases there is marked 
dyspnea, especially on inspiration, and a loud stridor as the air is drawn 
through the narrowed opening of the glottis. This may often 
be heard in an adjoining room. There is seen on inspiration deep 
recession of the suprasternal fossa, the supraclavicular spaces, and the 
epigastrium; also depression of the intercostal spaces, and even of the 
walls of the chest. Any excitement increases the spasm and aggravates 
the dyspnea. The distress may be great; the breathing usually slow 
and labored ; the voice hoarse, but rarely lost ; the cough stridulous, 
hoarse, and metallic ; the pulse rapid ; the temperature normal or slightly 
elevated, rarely over 101° F. There may be slight lividity of the finger- 
tips and of the lips, and sometimes considerable prostration. In the 
course of three or four hours the attack slowly wears away and the child 
falls asleep. During the following day, aside from slight hoarseness 
and occasional cough, he is apparently well. Most of the cases are 
not so severe as this ; there are the croupy cough, the hoarseness and gen- 
eral discomfort, but not marked dyspnea. On the second night there 
is a repetition of the experience of the first, usually quite as severe 
unless affected by treatment; and on the third day a remission similar 
to that of the day previous. On the third night the attack, if it occurs 
at all, is generally a mild one. Slight hoarseness persists for several 



CATARRHAL SPASM OF THE LARYNX 407 

days, but otherwise the child is apparently well. Many children have 
such attacks every few weeks in the course of the cold season, the slight- 
est exposure or an indiscretion in diet being sufficient to induce one. 

Prognosis. — This is good, the disease never proving fatal, although 
nothing is more alarming, at least to parents, than to witness for the 
first time one of these severe attacks of catarrhal croup. 

Diagnosis.— Catarrhal spasm may be confounded with laryngismus 
stridulus, acute catarrhal laryngitis or with membranous croup. Laryn- 
gismus stridulus occurs only in infancy. In it there is not simply stridu- 
lus breathing, but periods of complete arrest of respiration. These 
may be repeated many times during the day, and may continue for 
weeks, being often complicated by carpopedal spasm, sometimes by gen- 
eral convulsions. 

From acute catarrhal laryngitis and membranous laryngitis, catar- 
rhal spasm is distinguished by its sudden onset, the mildness of the 
symptoms of inflammation, the spasmodic character of the dyspnea, and 
the daily remissions. The history of previous attacks will often aid 
in diagnosis. In case of doubt, a positive diagnosis can often be made 
by allowing the child to inhale a little chloroform. This at once relieves 
dyspnea due to spasm, while it has scarcely any effect upon that due to 
inflammation or membrane. 

Treatment.— -The purpose of treatment during the attack is to pro- 
duce relaxation of the laryngeal spasm. This is accomplished by the use 
of emetics, steam, and hot fomentations over the larynx. To produce 
vomiting, ipecac is the safest drug. This may be given in the form 
of the syrup, one-half teaspoonful every ten or fifteen minutes to a 
child of two years until vomiting occurs, or it may lie com bine* I with 
ten or fifteen drops of the wine of antimony. The latter should not 
be repeated more than once or twice as it may produce serious depres- 
sion. When given at longer intervals these remedies are useful in relax- 
ing spasm without causing emesis. 

Emetics have a double value if the attack is due to indigestion. If 
there is constipation, an enema should be given. Following the free 
vomiting there is generally some improvement in (he symptoms, hut 
there may be a recurrence of the spasm unless other means are em- 
ployed. To prevent this, antipyrin is one of the most useful drugs. 
One grain may be given to a child one year old. This may he repeated 
every two hours if necessary. Quite as much relief as thai obtained Prom 
the drugs mentioned is seen from the use of steam inhalations. For 
this purpose the child should he placed in a closed tent, and steam intro- 
duced from a croup kettle. This may he used in conjunction with other 
measures, and continued as long as accessary. Poultices or hot fomen- 
tations over the larynx are also useful. In one case mi which severe 



468 DISEASES OF THE RESPIRATORY SYSTEM 

spasm had recurred for eight successive nights in spite of everything 
that was tried, the child being in great distress from the dyspnea, 
intubation was performed with instant relief. Tracheotomy, however, 
would scarcely be advisable. 

During the day following the first night attack, the child should 
be kept in a warm room, and it is well to continue the ipecac in doses 
too small to produce vomiting. After 6 p.m. the doses should be doubled, 
and at bedtime two grains of antipyrin given. If so treated, the symp- 
toms may not recur upon the second night, or there may be only the 
cough without the severe dyspnea. The child should be confined to 
the house for two or three days after one of these attacks, the drugs be- 
ing gradually reduced; but the antipyrin should be given at bedtime 
for three or four successive nights. 

To prevent a repetition of the attacks and remove the tendency to 
them, it is most important that the child should have plenty of fresh air 
and cold bathing, especially cold sponging about the neck and chest. 
Everything which experience has shown to bring on the attack should be 
carefully avoided. Local causes, such as adenoid growths and hyper- 
trophied tonsils, should receive appropriate treatment. Generally it is 
not necessary to exclude fresh air from the sleeping room. Although an 
open window on a cold, damp night may sometimes excite an attack, 
plenty of fresh air regularly given tends rather to diminish the suscep- 
tibility. If the child's condition is poor, general tonic treatment is to 
be employed. 

ACUTE CATARRHAL LARYNGITIS 

Acute laryngitis is not so frequent as the disease just described, 
although it is much more severe, and may even be fatal. It occurs espe- 
cially in children from one to five years of age, usually in the cold 
season. Predisposition to attacks is induced by the same conditions as 
in the case of acute rhinitis. Catarrhal laryngitis may be primary, when 
it is usually excited by cold or exposure, 1 or it may be secondary to 
measles, influenza, scarlet fever, or other infectious diseases. It may 
also be of traumatic origin, from the inhalation of steam or irritating 
gases. 

1 The following case is a good illustration of a severe attack excited by cold: 
A rather delicate infant, eight months old, was taken out, with very scanty 
covering, on a raw December day. In a few hours hoarseness and stridor were 
noticed, and the temperature was 101° F. ; three hours later it was 103° F., 
and in spite of the usual remedies which were employed the dyspnea had reached 
such a degree as to require intubation. The tube was worn only three days 
and the child made a prompt recovery. 



ACUTE CATARRHAL LARYNGITIS 469 

Lesions. — There is a moderately intense congestion of the laryngeal 
mucous membrane, sometimes general and sometimes localized. This 
may be seen with the laryngoscope, but is not always visible after death. 
With the congestion there are swelling and dryness, followed by increased 
secretion. In the milder cases the process is limited to the mucosa. In 
the more severe cases it involves the submucosa also, which is congested, 
edematous, and may be infiltrated with cells. The changes are especially 
marked in the lymphoid tissue of the subglottic region. The swelling 
may be sufficient to produce a very marked degree of laryngeal stei. 
In many mild and in all the severe cases there is associated catarrhal 
inflammation of the trachea, and often of the larger bronchi. In young 
children there is very little tendency to edema of the glottis. 

Symptoms. — In the mild form, such as that which is usually seen in 
older children, there is hoarseness, or even loss of voice, and a laryngeal 
cough which is sometimes hard and teasing and always worse at night. 
There may be pain and soreness over the larynx. Constitutional symp- 
toms are mild or absent, the patient not usually being sick enough b _ 
to bed, and often rebelling even at being kept indoors. The duration 
of the disease is from four to ten days, with a strong tendency to rel;i 
from slight causes. 

The severe form of catarrhal laryngitis is sometimes preceded by 
acute coryza, or there may be mild laryngeal symptoms for a few days 
before the development of the more severe ones. In other cases the 
disease develops rapidly and severe symptoms are present within a few 
hours from the onset. 

When the case is fully developed the voice is metallic and hoarse, 
and occasionally but not usually lost. There is a hoarse, dry. barking 
cough, which is very distressing, and sometimes almost constant. The 
cough, like the voice, is stridulous, and more or less stridor is presenl on 
inspiration. There is a slight amount of constant dyspnea, but this is 
scarcely noticeable unless the chest is bared. Severe dyspnea occurs in 
paroxysms, usually at night. Then, we may get the signs of obstructive 
dyspnea similar to those mentioned in severe attacks of catarrhal spasm. 
This dyspnea is chiefly inspiratory, but in some cases it in< tead- 

ily from the beginning of the attack, and may be indistinguishable from 
that due to membrane. Constitutional symptoms are usually presenl and 
may be severe. The temperature ranges in mosi cases from 1"' 
103° F., but may go to 104° or lor>° F. 'Hie pulse is rapid and full and 
respiration is accelerated. Children sometimes complain of pain h 
larynx and trachea which is increased by coughing. The symptom* 
severe for two or even three days, the fever continuing with i 
prostration and paroxysms of dyspnea, sometimes even atl 
focation and cyanosis. Dsually after tun or three days there is ;i grad- 



470 DISEASES OF THE RESPIRATORY SYSTEM 

nal subsidence of the dyspnea and the inflammatory symptoms, and the 
case goes on to recovery. At other times the inflammation extends down- 
ward to the large and then to the small bronchi, and finally results in 
bronchopneumonia. The attack may prove fatal from laryngeal obstruc- 
tion due to swelling and spasm. 

Diagnosis. — This disease is chiefly ,to be distinguished from mem- 
branous laryngitis. The onset of the two diseases may be very similar, 
and for the first twelve hours we have no absolute means of distinguish- 
ing between them, except possibly by the use of the laryngoscope, which 
is often conclusive in older children but not usually so in infants. All 
cases, therefore, should be looked upon with a degree of apprehension. 
The temperature in the catarrhal is usually higher than in the mem- 
branous form. The dyspnea is mainly paroxysmal, with daily remis- 
sions and nightly exacerbations, and is chiefly inspiratory, while that of 
membranous laryngitis is constant, steadily and often rapidly increas- 
ing, and is present both on inspiration and expiration. In catarrhal 
laryngitis the voice is not usually lost, but in the membranous form this 
is the rule. There can be little room for doubt when there are enlarged 
glands, membranous patches on the tonsils, and nasal discharge. Very 
often, however, all these evidences of diphtheria are wanting, the really 
difficult cases being those in which the process begins in the larynx. The 
prevalence of diphtheria and a known exposure count for something in 
favor of membranous laryngitis. If cultures from the pharynx show 
the presence of Klebs-Loeffler bacilli, diphtheria of the larynx is certain ; 
but no conclusions can be drawn from negative cultures. In catarrhal 
as well as in membranous laryngitis there may be extreme dyspnea, 
cyanosis, pallor, prostration, and even death. 

Prognosis. — This depends somewhat upon the cause of the disease 
and also upon the age of the patient. It is much worse when it is sec- 
ondary to measles or scarlet fever. It is better in children over three 
years of age than in infants, also when the general condition of the 
child is good. The prognosis in severe catarrhal laryngitis should always 
be guarded, not only on its own account, but also because it is impos- 
sible at first to be certain that the case is not one of membranous 
laryngitis. 

Treatment. — In all cases children affected are to be kept in bed, and 
the temperature of the room should be between 70° and 72° F. The diet 
should be light and fluid, and the bowels should be freely opened. A 
hot mustard foot bath should be given at the outset. Antipyrin (one 
grain every two hours to a child two years old) is useful if there is 
much spasmodic dyspnea. For this symptom emetics are beneficial, 
given as in catarrhal spasm. The use of ipecac and squills in smaller 
doses than is required for emesis (five drops each of the syrups of ipecac 



SUBMUCOUS LARYNGITIS— EDEMA OF THE GLOTTIS 471 

and squills every two hours) may give relief, especially in the early si 
when the cough is dry, hard, and severe. 

All the remedies mentioned are to be regarded as accessories to the 
essential treatment, which consists in the use of inhalations. The child 
should be placed in a tent into which steam is introduced from a croup 
kettle. Simple steam may be used, or pine needle oil, compound tincture 
of benzoin, lime-water, or creosote may be added. In moderately se 
cases inhalations should be used for fifteen minutes every two hours; 
in very severe ones they should be continued the greater part of the 
time. Poultices or hot fomentations may be applied over the larynx. 
Relief is sometimes obtained by using counter-irritation by mustard. 
In our experience the local use of cold is very unsatisfactory, on account 
of the difficulty of applying it properly, and the objection to it on the 
part of young children. Stimulants may be required late in the disease, 
the amount of prostration being the guide to their use. 

In cases of extreme dyspnea operative interference may be needed. 
It is required more often in infants and young children than in those 
who are older. Opinions will of course differ as to when the dyspnea 
has reached the danger point. One should not wait for general cyanosis. 
If pallor, marked prostration, and steadily increasing dyspnea are pres- 
ent the ca.-e should not be allowed to go on without interference, even 
though one may be perfectly sure that it is one of catarrhal inflam- 
mation only. The severity of the dyspnea is the only guide; cases at 
autopsy may turn out to be catarrhal, which were regarded during 
life as undoubtedly membranous. If intubation is done, the tube can 
generally be dispensed with in two or three days. Convalescence is 
usually rapid, but there is danger of recurring attacks during the 
remainder of the cold season. 



SUBMUCOUS LARYNGITIS— EDEMA OF THE GLOTTIS 

These two conditions are not quite identical, although they are closely 
associated and may be conveniently considered together. They are both 
rare in early life. In true edema of the glottis there is simply a drop- 
sical effusion into the submucous cellular tissue of the aryteno-epiglottic 
folds, causing them to project as large rounded swellings on either side 
of the superior isthmus of the larynx. They may he of sufficienl 
to cause serious or even fatal obstruction to respiration. With the laryn 
goscope they appear as pale-red tumor>. lying usually in contad oear 
the base of the tongue. By the finger their presence can he quite readily 
distinguished. Edema of the glottis occurs principally in the late Bt 
of nephritis. 



472 DISEASES OF THE RESPIRATORY SYSTEM 

In the inflammatory form of edema, or trne snbmncons laryngitis, 
there is the same sort of swelling of these structures, but in this case 
it is due to some active inflammation in the neighborhood. The swell- 
ing is partly from the edema and partly from cell infiltration. Usually 
all the parts surrounding the upper opening of the larynx are in a state 
of acute inflammation. The epiglottis may be swollen to the thickness 
of a finger and easily seen by depressing the tongue. 

The exciting causes may be the mechanical irritation of a foreign 
body, the inhalation of steam or irritating gases, erysipelas of the neck, 
primary catarrhal laryngitis, or retropharyngeal abscess. 

The symptoms consist of great inspiratory dyspnea with attacks of 
suffocation, while expiration may be quite easy. In true edema there 
are in addition the symptoms of the primary disease. In the inflamma- 
tory form there are the evidences of local inflammation — hoarseness, 
cough, pain, and difficulty in swallowing. A positive diagnosis may be 
made by a digital examination. The symptoms may develop with 
great rapidity in either variety, and frequently prove fatal in a few 
hours. 

The treatment of true edema consists in scarification or multiple 
puncture, the application of ice externally, and even the swallowing of 
ice ; in the inflammatory form, in addition, local blood-letting by leeches 
and, as a last resort, tracheotomy. Intubation is useless in either form. 



CHRONIC LARYNGITIS 

The following varieties are seen: (1) A simple form usually asso- 
ciated with adenoid vegetations of the pharynx; (2) tuberculous; (3) 
syphilitic; (4) that associated with new growths. 

1. With Adenoid Growths of the Pharynx. — This is not uncom- 
mon. A slight superficial catarrhal inflammation develops, the symptoms 
of which may continue for many months. These cases are often treated 
for a long time unsuccessfully by the use of sprays, inhalations, etc., 
but the symptoms disappear rapidly after the removal of the adenoid 
growths. Similar symptoms may be associated with hypertrophic 
rhinitis. In this also the treatment should be directed to the primary 
condition. 

2. Tuberculous Laryngitis. — This belongs to later childhood, and is 
rare even then. In infancy it is almost unknown. Eheindorf has re- 
ported a case in a child of thirteen months, which was regarded during 
life as syphilitic, but was shown by autopsy to be tuberculous. Of six- 
teen cases in children, reported by Rilliet and Barthez, none occurred 
during the first three years, and only four before the seventh year. The 



CHRONIC LARYNGITIS 473 

larynx alone may be affected, or the larynx and trachea, or the larynx, 
trachea, and lungs. Pulmonary tuberculosis is usually found to be 
present at autopsy, even though there may have been no pulmonary 
symptoms. Demme has reported a case of tuberculous laryngitis in a 
boy of four years whose lungs were healthy, death resulting from tuber- 
culous meningitis. 

The symptoms are hoarseness, aphonia, laryngeal cough, and muco- 
purulent, sometimes bloody, expectoration. The sputum may contain 
tubercle bacilli. With the laryngoscope tuberculous deposits may be 
seen, but more frequently there is tuberculous ulceration of the mucous 
membrane. In children this is usually superficial, the deep destructive 
ulceration seen in adults being very rare. 

It is to be differentiated from syphilis chiefly by the general symp- 
toms, as the laryngoscopic appearances may be very similar. Local 
treatment is seldom necessary and only with older children. It should 
be in the hands of a specialist. 

3. Syphilitic Laryngitis, — In the early stage of syphilis the larynx is 
often the seat of a catarrhal inflammation, which presents nothing espe- 
cially characteristic except its protracted course. The laryngitis of late 
hereditary syphilis is quite rare, and is likely to be overlooked because 
of the difficulties in the way of a thorough examination, and because the 
disease is usually painless. 

Strauss has collected fourteen cases between the ages of three and 
fifteen years, and added three of his own. He states that deep seated 
processes are much more rare than among adults. The parts most fre- 
quently affected are, first, the epiglottis; secondly, the aryteno-epiglottic 
folds; thirdly, the posterior laryngeal wall. The epiglottis was involved 
in twelve of fourteen cases. Usually there was only perichondritis; in 
the more severe cases there was partial or complete destruction of the 
cartilage. In four cases papillomatous masses were seen. In five cases 
the process extended from the epiglottis to the epiglottic folds of one 
or both sides. In several instances the superior vocal cords were thick- 
ened from hyperplasia, and occasionally small tumors were formed. 
In only one case was there ulceration of these folds. Changes in the 
vocal cords and the arytenoid cartilages were rare, occurring only with 
extensive inflammation. The symptoms are those of chronic laryngitis: 
hoarseness, sometimes aphonia, and in a few cases chronic laryngeal 
stenosis. The diagnosis can be made only by means of the laryngoscope, 
In most of the cases there are present ulcerations of the palate or uvula. 
or scars from previous ulcers; sometimes the disease extends into the 
nose. Serious symptoms often result when to old syphilitic lesions there 
is added acute laryngitis or edema. 

In addition to the usual constitutional remedies for syphilis and 



474 DISEASES OF THE RESPIRATORY SYSTEM 

to the means ordinarily employed for the relief of chronic laryngitis, 
intubation may be required in these cases for the relief of laryngeal 
stenosis. The tube must usually be worn for many months. 



NEW GROWTHS 

New growths of the larynx are not very rare in children. Excluding 
the granulations which follow the use of the tracheal canula, the only 
one that is likely to be met with is papilloma. This may occur even in 
infancy. According to Kauchfuss, the majority of the cases begin dur- 
ing the first year. Boys are more frequently affected than girls. 

The symptoms depend upon the size and location of the tumor. The 
earlier manifestations are usually ascribed to chronic laryngitis. There 
is hoarseness, sometimes loss of voice, and a paroxysmal cough; later, 
dyspnea develops which often increases by paroxysms. The symptoms 
are slowly progressive, and it may be several months before they are suf- 
ficiently severe to attract special attention. A positive diagnosis is made 
only by the laryngoscope. There is seen a whitish granular tumor or 
tumors, sometimes pedunculated, sometimes with a broad base, which 
may be attached to any part of the larynx. The prognosis is usually seri- 
ous on account of the danger of bronchopneumonia after operation. 

The treatment of these cases belongs to the specialist. Operative 
removal of these papillomata usually results in their recurrence in 
increased numbers. For this reason operations through the mouth have 
been largely given up. Papillomatous tumors will often disappear en- 
tirely if complete rest for the larynx is secured by means of tracheotomy ; 
but the tube must be worn for from six months to a year. Eadium has 
been used in a few instances with brilliant results, the tumor disappear- 
ing after a single application and not recurring ; but extensive cicatriza- 
tion has also been reported. 



FOREIGN BODIES IN THE LARYNX AND BRONCHI 

The aspiration of foreign substances into the larynx is not an un- 
common accident in children. It usually happens from an attempt to 
cough, laugh, or cry while the child has something in his mouth. If 
the body is sharp and irregular, like a pin, the shell of a nut, or a frag- 
ment of bone, it is liable to become impacted in the larynx. If smooth, 
like a pea or a bead, it is usually drawn into one of the bronchi, generally 
the right. 

When the body enters the larynx there is immediately excited a 



FOREIGN BODIES IX THE LARYNX AXD BRONCHI 475 

violent paroxysmal cough, with dyspnea amounting almost to suffoca- 
tion. Often the body is dislodged by this initial attack of coughing. 
If it becomes impacted in the larynx, it may cause sudden death by 
occluding the glottis; elsewhere it may excite acute laryngitis, usually 
of considerable severity. 

The impaction of a foreign body in one of the primary bronchi, or 
one of the lobar divisions, is indicated by cough and a severe localized 
pain in the chest. There may be expectoration of blood. On auscultat- 
ing the chest, there is found an absence of respiratory murmur over one 
lung or one lobe, according to the situation of the foreign body. Percus- 
sion usually gives marked dulness, the signs thus suggesting pleural 
effusion; or there may be increased resonance, which may even be 
tympanitic, owing to diminished tension in the part of the lung involved 
and to the emphysema which rapidly develops in the surrounding lung. 
If the foreign body remains impacted in one of the bronchi, it usually 
excites a localized inflammation, which may terminate in the formation 
of an abscess. This may result fatally, or there may follow a prolonged 
illness, with hectic symptoms resembling pulmonary tuberculosis; and 
finally, after weeks or months, the foreign body may be expelled by 
an attack of coughing, and the patient recover completely. In other 
cases no abscess develops but there are repeated attacks of acute 
pneumonia which never entirely resolve so that chronic pneumonia 
of an intense degree develops. The general health is greatly inter- 
fered with and the child usually succumbs to one of the recurrenl acute 
attacks. 

The diagnosis of a foreign body in the larynx is made by the sudden- 
ness of attack and the violence of the early symptoms. In older chil- 
dren the body may be seen with the laryngoscope, but in young children 
this is very difficult. The position of a metallic or solid body may be 
revealed by the X-ray. The prognosis is always doubtful, and depends 
upon the nature of the foreign body and the point at which it has been 
arrested. The usual cause of death either with or without, operation is 
bronchopneumonia. 

The first thing to be tried is inversion of the patient. By this 
means, assisted by the cough, the foreign body is not infrequently es 
pelled even though it has passed below the larynx. The symptoms of 
laryngeal obstruction may call for immediate tracheotomy or laryn- 
gotomy, intubation not being applicable to these cases, [f, after trache- 
otomy, the foreign body can be Located in the larynx, Imi can nol 
he extracted through the tracheal wound, the thyroid cartilage should 
he divided in the median line. The removal of a foreign body from the 
bronchi or the tracheal bifurcation Bhould be attempted onl) bj one 
skilled in bronchoscopy. 



476 DISEASES OF THE RESPIRALORY SYSTEM 

CHAPTER III 
DISEASES OF THE LUNGS 



THE PECULIARITIES OF THE LUNGS IN INFANCY AND EARLY 

CHILDHOOD 

Thorax. — The general shape of the thorax is somewhat cylindrical, 
the conical or dome-shape of the adult thorax not being attained until 
puberty. The antero-posterior and the transverse diameters are nearly 
equal in the newly born, but after the third year the transverse diameter 
is always greater, the difference increasing steadily up to adult life. On 
account of the shape of the chest, the lungs are situated rather more 
posteriorly in the infant than in the adult. 

The thoracic walls are very elastic and yielding, owing to the carti- 
laginous condition of a large part of the framework. They are relatively 
thinner than in the adult, chiefly from the imperfect development of the 
thoracic muscles. The greater part of the thickness of the thoracic walls 
is due to the deposit of fat, generally abundant in well-nourished in- 
fants; but where the fat is scanty the walls are extremely thin. The 
capacity of the thorax is considerably encroached upon by the high posi- 
tion of the diaphragm, the large size of the thymus gland, and the fre- 
quent distention of the stomach and intestines. 

Respiration. — According to Uffelmann, the rapidity of respiration 
during sleep at the different ages is as follows: 

At birth 35 per minute. 

At the end of the first year 27 " " 

At two years 25 " a 

At six years 22 " " 

At twelve years 20 " * 

During waking hours this rate is very materially increased, and 
from comparatively slight disturbance it may be nearly twice as 
rapid. 

The type of respiration in infants is diaphragmatic, and it continues 
to be chiefly so until after the seventh year, when the costal element 
gradually becomes more and more prominent. The rhythm of respira- 
tion is easily disturbed. In very young infants the regular rhythm is 
seen only in sleep. The lungs do not always expand equally; at certain 
times and in certain positions respiration may be carried on for a few 
moments almost entirely with one lung. For some moments it may be 
very superficial, and then quite deep. The length of the interval between 



THE PECULIARITIES OF THE LUNGS IN INFANCY 477 

inspiration and expiration varies much at different times. Regular 
rhythmical respiration is not fully established before the end of the 
second year. After this time disturbances of rhythm are due chiefly 
to pulmonary or cerebral disease; but in infancy quite marked irregu- 
larity may have little or no significance. It is very common in all 
asthenic conditions. 

Structure. — As compared with the adult, the trachea of the young 
child is larger; the bronchi are larger and occupy a greater space; the 
air cells are much smaller and occupy less space; and the interstitial 
tissue is much more abundant. 

Physical Examination. — This requires tact and time, but yields re- 
sults which are quite as satisfactory as in adults. It should be under- 
taken only in a room having a temperature of about 70° R, or before 
an open fire. 

Inspection.— This should be made with the chest bare. There should 
be noted, the shape of the chest, the presence of deformities from rickets, 
the want of symmetry in the two sides, bulging of the intercostal spaces, 
whether the two lungs expand equally or not, also variations in rhythm, 
and the presence and extent of any recession of the soft parts or bony 
walls as an indication of obstructive dyspnea. 

Palpation. — This also should be made upon the bare skin, always 
with the hand well warmed. Although we can not get the fremitus of 
the ordinary voice, we can get that of the cry. This is usually more 
intense than in adults, on account of the thinness of the chest walls. We 
frequently get a bronchial fremitus — a vibration produced by mucus in 
the tubes. The position of the apex beat of the heart should be deter- 
mined, it being remembered that in infancy this is normally in the 
mammary line, or just inside of it, and usually in the fourth intercostal 
space. 

Percussion. — For the examination of the back, the child may be laid 
face downward upon the nurse's lap, or be seated upon her arm. For 
the front and the lateral regions of the chest, the child is most con- 
veniently placed upon his side across a hard pillow. The percussion blow 
must be light, either with a single finger or a small percussion hammer. 
Percussion should be made both during inspiration and expiration. The 
normal percussion note is somewhat tympanitic this being due to the 
relatively large bronchi and the thin chest walls. This aote is exag- 
gerated in the interscapular region and beneath the clavicle, especially 
upon the right side. Here cracked-pot resonance may he obtained even 
in health. 

Auscultation. — This may be practiced with the naked car or with the 
stethoscope. A stethoscope is absolutely necessary for a thorough exam- 
ination of the apices of the lungs in front and the axillary regions. 
17 



478 DISEASES OF THE RESPIRATORY SYSTEM 

Most children are less frightened by the instrument than by the head of 
the physician during anterior auscultation. 

The normal respiratory murmur of the infant is generally described 
as "puerile." In quality this has been likened to the bronchial breath- 
ing of the adult, but the resemblance is not a very close one. It is rude, 
rather loud, and seems very near the ear. Its peculiar character is due 
to the fact that the tracheal and bronchial sounds are more distinct, 
because not transmitted through so thick a layer of lung and chest wall. 
It is especially loud in the regions where the bronchi are superficial, as 
between the shoulder-blades and beneath the clavicles, particularly of 
the right side. A careful comparison of the two sides of the chest will 
generally enable an observer to avoid errors. The irregularity of rhythm 
which occurs from slight causes should be remembered, and the infant's 
position changed several times during auscultation, to avoid the mis- 
take of attaching too much importance to a feeble respiratory murmur 
of one side. 

On account of the thinness of the chest walls, there is difficulty in 
distinguishing between rales produced in the bronchi and pleuritic fric- 
tion sounds. Before drawing any inference from the auscultatory signs, 
both lungs must be examined for several minutes, changing the child's 
position, and often inducing a cry or compelling a deep inspiration by 
other means, in order to bring out signs which otherwise may be over- 
looked. As auscultation is extremely difficult or impossible in a crying 
infant, this part of the physical examination should be made first if the 
child is quiet, since upon it we must chiefly depend for diagnosis. In- 
spection and percussion can be deferred until later. 

Peculiarities in Disease. — There are several peculiarities connected 
with the respiratory organs in infancy and early childhood which must 
be constantly borne in mind in studying their diseases. The muscular 
development of the thoracic wall is feeble. The soft, }delding character 
of the thoracic framework causes the chest to- sink in readily from at- 
mospheric pressure whenever there is obstructive dyspnea. On account 
of the small size of the air vesicles, acute congestion may interfere 
with their function almost as completely as does consolidation. Because 
of the delicate walls of the air vesicles, emphysema is readily produced 
in obstructive dyspnea, but it is rarely permanent. There is a tendency 
to collapse, either on the part of lobules or groups of lobules, but very 
rarely of an entire lobe. This is a much less important factor in the 
production of symptoms in acute pulmonary disease than many writers 
would lead us to suppose. The tendency of inflammation to spread from 
the large to the small bronchi is much greater than in adults. In all 
forms of pulmonary disease the rapidity of respiration is much greater 
than in adults. Areas of consolidation often exist without appreciable 



ACUTE CATARRHAL BRONCHITIS 479 

changes in the percussion note, because they are superficial and are sur- 
rounded by healthy or emphysematous lung. Flatness should always 
suggest the presence of fluid. 

Probably the most common mistakes are to confound bronchial rales 
with friction sounds, exaggerated puerile breathing with bronchial breath- 
ing, and to' overlook the existence of fluid because of the presence of 
bronchial breathing. 



ACUTE CATARRHAL BRONCHITIS 

Acute catarrhal bronchitis is one of the most frequent conditions for 
which the physician is called upon to prescribe in children. It occurs at 
all ages, from early infancy up to puberty. Its frequency, however, 
diminishes steadily after the second year. The predisposition to acute 
bronchitis exists with the same constitutional conditions, and is acquired 
in the same manner as the predisposition to the acute catarrhal inflam- 
mations of the upper respiratory tract. (See Acute Rhinopharyngitis.) 
Bronchitis is very common in children who are suffering from rickets and 
malnutrition. It is much more frequent in the cold months, especially 
in the late winter and early spring, when there are sudden atmospheric 
changes and high winds. The presence of large tonsils and adenoid 
vegetations of the pharynx are important predisposing causes. 

Bronchitis may be a primary or a secondary disease. The primary 
form is excited by cold, exposure with insufficient clothing in severe 
weather, wetting of the feet, or chilling of the surface in any manner. 
Under these conditions it may occur alone, or be associated with or 
preceded by acute catarrh of the nose, pharynx, or larynx. In rare c 
it is caused by the inhalation of irritants. Bronchitis is an almost in- 
variable accompaniment of measles and influenza. It is very common 
in pertussis, in scarlet and typhoid fevers, and diphtheria, and may 
occur in any acute infectious disease; it also complicates pneumonia and 
pleurisy. The microorganisms associated with bronchitis are chief} 
the staphylococcus aureus and the pneumococcus, often in combination; 
next in importance are the streptococcus and. especially in protracted 
cases, the influenza bacillus. 

Lesions. — Acute catarrhal bronchitis is an inflammation of the 
mucous membrane of fin' bronchi. As a rule it is bilateral, both sides 
being involved to the same degree. Localized bronchitis is secondary to 
some other pathological process in the lungB, usually tuberculosis, "Id 
pleuritic adhesions, or pneumonia. In acute bronchitis only the lai 
tubes may be affected, this usually being complicated with inflammation 
of the trachea (ordinary tracheobronchitis) ; or, in addition, the pro 



480 DISEASES OF THE RESPIRATORY SYSTEM 

may extend to the medium-sized tubes (severe bronchitis) ; or, in infants 
especially, it may extend to the smallest tubes (capillary bronchitis). 
In the last-mentioned form there are invariably changes in the zones 
of air vesicles surrounding the bronchi, and these cases are therefore 
more properly classed as bronchopneumonia. In the first form the in- 
flammation is superficial, and affects only the mucous membrane of the 
bronchi. In the second form it may involve the entire thickness of the, 
bronchial wall, and in the third form it does so regularly, 

The pathological changes consist in congestion and swelling of the 
mucous membrane, desquamation of the epithelium, and an exudation of 
mucus and pus cells. At autopsy the injection of the mucous membrane 
is usually distinct ; pus and mucus cover the surface of the larger bronchi, 
and by pressure ooze from the cut extremities of the smaller tubes. The 
chief lesion of the walls of the bronchi consists in an infiltration with 
leucocytes. In infants dying fronubronchitis, the lungs are much more 
frequently emphysematous than collapsed. In fact the readiness with 
which emphysema occurs in bronchitis is one of its distinguishing feat- 
ures in infancy. However, this is rarely permanent but usually sub- 
sides rapidly after the acute attack is over. There is swelling of the 
lymph nodes at the root of the lungs, which in most of the acute cases 
is slight, but in protracted cases, and after recurring attacks, may be 
quite marked. 

Symptoms. — It is convenient to consider separately the symptoms in 
infants and in older children. 

The Bronchitis of Infants. — 1. The Mild Form (Bronchitis of 
the Larger Tubes.) — The onset is generally gradual, and the symptoms 
of bronchitis may be preceded by those of catarrh of the nose, pharynx, 
or larynx. The change in the character of the cough, the slightly ac- 
celerated breathing, and a further rise in temperature, indicate an ex- 
tension to the bronchi. The cough may be constant and severe, or very 
slight. There is no expectoration^ The secretions are usually coughed 
up into the mouth or pharynx, and swallowed. This sometimes excites 
vomiting. At other times the mucus is coughed only into the trachea 
or larynx, and aspirated again into the lungs. The respirations are from 
forty to fifty a minute, and often accompanied by a rattling sound, due 
to mucus in the large bronchi or trachea. The general symptoms are 
not severe, and unless the infant is very young or very delicate no ap- 
prehension need be felt as to the outcome. The temperature is generally 
from 100° to 102° F. for two or three days, then below 100° F. A mod- 
erate amount of restlessness dependent upon the severity of the cough, 
anorexia, and sometimes vomiting and diarrhea, are usually present. 

The physical signs in the first stage are dry, sonorous rales over the 
whole chest. A little later these give place to coarse mucous rales heard 



ACUTE CATARRHAL BRONCHITIS 481 

everywhere, but especially distinct between the scapulae and in the infra- 
clavicular regions. On palpation there is usually a marked bronchial 
fremitus. Often there is not' enough dyspnea to cause recession of the 
soft parts of the chest. Unless the disease extends to the smaller bronchi 
and the air vesicles, the illness usually lasts about a week. Coarse rales 
in the chest may remain for some time after the symptoms have subsided. 
Eelapses are exceedingly common. In a delicate or rachitic child, or in 
one whose surroundings are bad, one attack is likely to be followed by a 
succession of others, so that the child may not be really well until warm 
weather comes. The general health may suffer from the prolonged con- 
finement to the house, although the patient may never have been seri- 
ously ill. 

2. The Severe Form (Bronchitis of the Smaller Tubes). — This dif- 
fers from the preceding variety mainly in the greater severity of all its 
symptoms. The onset may be like that just described, the severe symp- 
toms not appearing until the patient has been sick two or three days, 
or they may be severe from the outset. If the latter, it is indistinguish- 
able from bronchopneumonia. There is cough, dyspnea, accelerated 
breathing, fever, and moderate, sometimes severe, prostration. The 
cough is tighter, and more frequently of a short, teasing character than 
severe and paroxysmal. There is difficulty in nursing. Dyspnea may 
be quite marked and is shown by the active dilatation of the alae nasi and 
the recession of all the soft parts of the chest on inspiration. The 
respirations, as a rule, are from 50 to 80 a minute. The temperature 
for the first day or two is usually 100° or 102°*F., but it may be 103° 
or 104° F. So high a temperature does not continue unless pneumonia 
develops. The prostration is in most cases more closely related l<> the 
dyspnea and the rapidity of respiration than to the temperature. Often 
there is slight cyanosis. 

In the beginning the chest is filled with sibilant and sonorous rales. 
In twelve or twenty-four hours these are wholly or in part replaced by 
moist rales — coarse or fine, according as they are produced in the large 
or medium-sized tubes. The rales are always best heard behind, hut they 
are present all over the chest. The sibilant and sonorous breathing may 
persist throughout the attack and for a week or two thereafter. This 
prominence of the spasmodic or asthmatic element in bronchitis is char- 
acteristic of infancy and early childhood. The respiratory murmur i- 
feeble; the resonance! on percussion is normal or slightly exaggerated, is 
the case progresses toward recovery, the finer rales are the firsl to dis- 
appear. 

At the onset of such a case it is impossible to say whether the di 
will be limited to the medium-sized bronchi or will extend to the small* 
est bronchi and air vesicles. In young or very delicate infant-, and dur- 



482 DISEASES OF THE RESPIRATORY SYSTEM 

ing measles, it is very common for the disease to spread rapidly to the air 
vesicles. In other cases, usually in infants under six months old, there 
may develop attacks of respiratory failure or suffocation. These may 
occur in a severe case at any time, and, because of the infant's inability 
to empty the tubes of secretion, the dyspnea steadily increases until the 
respiratory muscles are exhausted. The symptoms which follow are 
usually ascribed to pulmonary collapse. It is, however, by no means 
certain that this is the correct explanation, for at autopsies made in such 
cases the lungs are usually found to be the seat of acute emphysema. 
The clinical picture is a clear one. There is no disposition to cough or 
cry; the pulse is feeble; the respiration very rapid, superficial, often 
irregular; the skin cyanotic, and often clammy. Finally, there may be 
added to the other signs, dulness, apathy, and stupor. Such attacks may 
come on quite suddenly even in robust infants, and unless the treatment 
is energetic, death often follows in a few hours, being frequently pre- 
ceded by convulsions. 

The usual course of the disease in infants previously in good health 
is that the severe symptoms continue for two or three days only, after 
which the temperature falls to 100° or 100.5° F., and gradually becomes 
normal. The constitutional symptoms usually decline with the tempera- 
ture, and, except during the first thirty-six hours, they rarely give cause 
for anxiety. Eecovery almost invariably occurs unless the disease ex- 
tends to the finer bronchi. 

Bronchitis is principally to be distinguished from bronchopneumonia. 
The differential diagnosis is more fully considered under that disease. 
The most important points are that in pneumonia the temperature is 
higher and more prolonged, the prostration greater, the rales very often 
localized — being heard only behind, often over only one lung — the dura- 
tion is more protracted, and all the symptoms are more severe. In 
nearly all cases of severe bronchitis in young children some pneumonia 
is present. 

The Bronchitis of Older Children. — This is not nearly so serious 
as in infants, because the same danger does not exist of extension of the 
inflammation to the finer bronchi and air cells. 

1. The Mild Form. — This is very common. The constitutional symp- 
toms are slight, and often entirely absent after the first day. The patient 
is never sick enough to go to bed. The first symptoms are cough and 
soreness or a sense of oppression beneath the sternum. The cough is 
always worse at night. It is at first tight, hard, and racking; later it is 
loose, and in children over five years old there is usually expectoration — 
first of white, frothy mucus, but after a few days it becomes more abun- 
dant, and of a yellow or yellowish-green color, from the presence of pus. 
The physical signs arc only coarse rales, at first dry, and later moist, but 



ACUTE CATARRHAL BRONCHITIS 483 

heard over both sides of the chest, in front and behind. There may be 
some disturbance of digestion, anorexia, constipation, or diarrhea. The 
usual duration of the attack is from one to two weeks. If the patient is 
not kept indoors the disease may pass into a subacute form, lasting for 
several weeks as a protracted "winter cough," but without any other im- 
portant symptoms. 

Such prolonged or recurring attacks of bronchitis of a subacute form 
should suggest influenza or tuberculosis. A positive cutaneous tuberculin 
reaction renders tuberculosis probable. A careful search for bacilli in 
the sputum should then be made. Although not found at first, if present 
repeated examinations will usually disclose them. Influenza can be 
diagnosticated with certainty only by sputum cultures. 

2. The Severe Form. — The onset is abrupt, with fever, chills, pains 
in the back, headache, cough, and sometimes pain in the chest. There is 
a feeling of tightness or constriction beneath the sternum. The onset 
resembles that of pneumonia, except that the symptoms are less severe. 
The temperature for the first two or three days ranges bet wen 100° and 
103° F. It is generally highest in the first twenty-four hours. The 
cough resembles that of the mild form, but it is usually more severe. 
The expectoration is more profuse, and occasionally, in the early stage, it 
may be streaked with blood. g 

The coarse rales of the mild form are present, and in addition t he re 
are finer rales — at first dry, and later moist — heard all over the chest. 
Frequently, wheezing rales are heard on expiration. The duration of the 
attack is ordinarily from two to three weeks, the patient being sick 
enough to be confined to bed for three or four clays only. There is fre- 
quently a cough for some time after all physical signs have disappeared. 
Relapses are easily excited by any indiscretion before the patient has 
quite recovered. 

The prognosis in the primary cases is good, such almost invariably 
terminating in recovery, and very exceptionally passing info broncho- 
pneumonia; but this not infrequently happens when the attack compli- 
cates measles or pertussis. 

Treatment of Bronchitis. — To remove the predisposition to bronchitis 
the same means should be employed as those mentioned in Acute Rhino- 
Pharyngitis. Children with tuberculous antecedents, and those who 
are especially prone to pulmonary disease, should, if possible, spend the 
winter in a warm climate. The sleeping apartments of susceptible in- 
fants should not be too cold — never below 55 I. -bid they should be 
well ventilated. It is important in infants and young children thai mild 
attacks of bronchitis should not be neglected. 

Every young child who has an acute catarrh of the oose, pharynx, 
larynx, or bronchi should be kepi indoors. In every such catarrh accom 



484 DISEASES OF THE RESPIRATORY SYSTEM 

panied by fever the child should be kept in bed while the fever lasts, even 
if the temperature does not go above 100.5° F., and is accompanied by 
no other constitutional symptoms. A very large number of the cases will 
recover promptly when no other treatment is employed than to keep the 
child in bed. Fresh air is indispensable. But the advantages of cold air 
have not yet been demonstrated. According to our experience, the wide- 
open windows have no place in the treatment of acute bronchitis in in- 
fants or young children in the winter and spring season. The tempera- 
ture of the room should be about 70° F. The room should be well 
ventilated and frequently aired, the child meanwhile being removed to 
another room. There is a great advantage in changing the child's posi- 
tion in the crib and from the crib to the nurse's arms. Careful attention 
should be given to feeding and to the condition of the bowels. A cathar- 
tic, preferably castor oil, should be administered at the outset. 

Poultices are objectionable and should not be employed. Counter- 
irritation is very valuable. In infants, good results are obtained by the 
frequent use of a mustard paste (see chapter on General Therapeutics). 
The paste may be repeated, according to indications, from two to five 
times a day. If properly used, it will not injure the skin. 

Inhalations may, in the great majority of cases, take the place of the 
administration of drugs by the mouth, a very great advantage in infants. 
They may be used by means of the croup kettle, the child always being 
placed in a tent. In the early part of the disease inhalations, like simple 
aqueous vapor or lime-water, may be used. Later turpentine, creosote, 
benzoin, terebene, or eucalyptol may be added. Of these, creosote usually 
gives the most satisfaction. Inhalations are to be used for ten or fifteen 
minutes from four to eight times a day. 

In infancy, expectorants may advantageously be dispensed with. 
For older children, antimony and ipecac may be used in the first stage. 
When the secretion is more abundant, creosote, turpentine, or terebene 
may be given. Small, frequently repeated doses usually give the best 
results. Opium should be given cautiously to infants. The dry, harass- 
ing cough of the early stage sometimes yields to nothing so quickly 
as to small doses of Dover's powder (e. g., one-tenth of a grain every 
two hours to a child of one year). The use of emetics to get rid of 
bronchial secretion is not to be advised. Stimulants are not required 
in most of the cases. The indications for them are the same as in pneu- 
monia. When there is much dyspnea of the asthmatic type, nothing works 
as well as epinephrin. It should be given intramuscularly; the dose is 
two to five minims of the 1-1,000 solution. The effects are almost im- 
mediate, but often only transient. 

Should attacks of suffocation and respiratory failure occur in infants, 
the indications are to excite respiratory movements and to get as much 



FIBRINOUS BRONCHITIS 485 

blood as possible to the surface and the extremities. Flagellation or 
spanking and the use, alternately, of hot and cold douches to the chest 
will sometimes induce the deep respiratory efforts desired. Other useful 
measures are the hot mustard bath and the mustard pack applied to the 
entire body. Probably the most effective of all remedies is dry cupping. 
The chest should be cupped front and back for five or ten minutes every 
few hours. Oxygen should be administered. As these symptoms are 
likely to recur every few hours for a day or two, a repetition of the 
treatment may be needed. For such patients cold air is injurious. They 
should be kept in a room with a temperature of 70° to 72° F. 

In the non-febrile cases in older children, confinement in bed is un- 
necessary, but they should be kept indoors. In the early stage, with 
hard, dry cough, one of the best remedies is brown mixture (the mis- 
tura glycyrrhizae composita of the U. S. P.). It will be found advan- 
tageous in most cases to have the formula made up with one-half the 
usual amount of opium. When the cough is especially hard and dry 
inhalations of steam are indicated. In the second stage, muriate of 
ammonia may be added to the brown mixture; or terebene, two or 
three drops upon sugar, may be given four or five times a day, and in- 
halations should be used several times a day. 

In the more severe cases the patients should be kept in bed and a coun- 
ter-irritant to the chest employed. For the general discomfort, pain, 
headache, etc., nothing is better than phenacetin and Dover's powder 
(two grains of the former to one-half grain of the latter to a child of 
five years), repeated every three to six hours. All patients should be 
kept in bed as long as the temperature is above normal. 

After all physical signs and constitutional symptoms have disappeared, 
a cough continues sometimes for weeks. Expectoration Is scanty, or is 
wanting altogether; the cough is hard, dry, often paroxysmal, and in some 
cases occurs at night only. For this condition the best remedies are rod- 
liver oil and creosote. When these measures are not effective, a change 
of climate should be advised. 



FIBRINOUS BRONCHITIS (Bronchial Croup) 

Fibrinous bronchitis is usually seen in diphtheria, as an extension 
from the larynx or trachea. There is, however, another form of bron- 
chitis attended by a fibrinous exudate, which occurs as a primary disease. 
This is very rare in children. Wei] has, however, collected twenty • 
of the primary form. The etiology is obscure. It ifi seen at all e 
from infancy up to puberty, and it may be either acute or chronic. From 
the cases thus far reported it would appear that the acute form is rela- 



486 DISEASES OF THE RESPIRATORY SYSTEM 

tively more common in children than in adults. The disease may be 
confined to certain branches of the bronchial tree, or it may affect all the 
bronchi, even to the minute subdivisions. The fibrinous membrane is 
found loose in the tubes or adherent. There are generally associated 
other pulmonary changes, such as emphysema, atelectasis or broncho- 
pneumonia. 

The acute form somewhat resembles ordinary catarrhal bronchitis. 
The diagnostic features are, the severity of the dyspnea and the expectora- 
tion of tube casts from the larger bronchi, or elongated cylinders from 
the smaller ones, the former resembling macaroni, the latter, vermicelli. 
The expectorated masses are often in balls or plugs, and their peculiar 
character is not recognized until they are placed in water. The casts 
are dissolved by alkalis, especially by lime-water. After the expulsion of 
a large cast, improvement in all the symptoms occurs. They, however, 
return as the exudate reappears. The ordinary duration of acute cases 
is from one to three weeks. 

In the chronic form there are no constitutional symptoms, but only 
dyspnea and cough, often recurring in paroxysms, with the expectora- 
tion of fibrinous casts. The patient may have these attacks at intervals 
of a few days or weeks, extending over a period of months, or even years. 
There are no characteristic physical signs. The diagnosis rests upon 
the peculiar character of the expectoration. The prognosis in acute cases 
is unfavorable, the mortality being 75 per cent (Weil). Chronic cases 
are not dangerous to life. 

Treatment. — This is quite unsatisfactory. To loosen the membrane 
and facilitate its expulsion, the most efficient means are inhalations of 
the vapor of lime-water. Pilocarpin is too dangerous for use with small 
children. Occasionally emetics are of value. Improvement in some of 
the chronic cases has resulted from the use of iodid of potassium. 



CHRONIC BRONCHITIS 

Chronic bronchitis is not a very common disease in children, partic- 
ularly in young children, one reason being that chronic emphysema, so 
frequently an associated condition in adults, is rather rare in early 
life. Chronic bronchitis always accompanies chronic pulmonary tubercu- 
losis and chronic interstitial pneumonia, with or without the occurrence 
of bronchiectasis. It is seen in chronic cardiac disease, especially with 
lesions of the mitral valve. It may occur as a late symptom of hereditary 
syphilis. Excluding the varieties mentioned, it usually follows attacks 
of acute bronchitis, the process becoming chronic because of the patient's 
constitutional condition or his unhygienic surroundings. The acute at- 



ASTHMA 487 

tack may be primary, but it often follows measles and whooping-cough. 
Deformities of the chest, the result either of rickets or of Pott's disease, 
are occasionally a cause. 

Symptoms. — The only constant symptom is cough, which is per- 
sistent, obstinate, and nearly always worse at night or early in the morn- 
ing. It often occurs in paroxysms strongly suggestive of pertussis. Ex- 
pectoration is not generally abundant, but in older children it is usually 
present, and in a few cases it is profuse. A copious morning expectora- 
tion of fetid pus or muco-pus indicates bronchiectasis. There is do 
fever, little or no dyspnea, and although the patients are thin, they are 
not emaciated, and in many cases the general health is not much affected. 
There may be coarse mucous rales, or no physical signs whatever. The 
duration of the disease is indefinite, depending upon the cause. All 
these patients are better in summer than in winter, and suffer fre- 
quently from exacerbations of acute or subacute bronchitis. 

The diagnosis is to be made mainly from pertussis and tuberculosis. 
From mild attacks of pertussis the diagnosis may be impossible except 
by the course of the disease. Tuberculosis may be suspected if the ther- 
mometer shows regularly a slight evening rise of temperature, if there is 
much anemia, and steady loss of flesh. It may, however, be present 
without any of these symptoms. A positive cutaneous reaction is sug- 
gestive, but a certain diagnosis can be made only by the discovery of 
tubercle bacilli in the sputum. 

Treatment. — The first indication is to treat the primary conditions 
upon which chronic bronchitis may depend. Attention should be directed 
to the general condition — rickets and malnutrition each receiving its 
appropriate treatment. In many cases a change of climate is the only 
thing which is really curative. The general health should be promoted 
as much as possible by a tonic plan of treatment which may advan- 
tageously include the use of cod-liver oil. The results obtained from 
drugs are not very satisfactory but the following may !»■ employed: 
potassium iodid, creosote and terebene, the last two being given both 
by mouth and by inhalation. For the relief of cough opiates are to be 
avoided as much as possible. 

ASTHM \ 

Asthma is characterized by attacks of severe spasmodic dyspnea, which 

may be preceded, accompanied, or followed by a bronchitis of gr< 
or less severity. In infancy, the association of asthma with bronchitii 
a very close one, and the cases presenl quite ;i differeni clinical picture 
from the disease as seen in older children, which differs in do essential 
points from the asthma of adults. 



488 DISEASES OF THE RESPIRATORY SYSTEM 

Writers differ very much in their statements regarding the fre- 
quency of asthma in early life, mainly because of a want of agreement in 
regard to what shall be included under this term. The asthmatic attacks 
of infants are considered by some as a stage of bronchitis, by others as 
distinct from that disease. Typical attacks resembling those of adult life 
are rare in children, and extremely so before the fifth year. How- 
ever, of 225 cases of asthma reported by Hyde Salter, the disease began 
before the tenth year in nearly one-third the number. 

Etiology. — The general or constitutional causes are the same in chil- 
dren as in adults. Asthma is often hereditary. It frequently occurs in 
children who in infancy have suffered from eczema. The local cause 
may be any form of irritation in the nose or pharynx — hypertrophic rhin- 
itis, adenoid growths of the pharynx, hypertrophied tonsils, or elongated 
uvula — or in the bronchial mucous membrane, as a result of previous 
attacks of acute bronchitis. It is probable that it may also be caused 
by the irritation of enlarged bronchial glands. In susceptible children, a 
paroxysm may be excited by high winds, dust, cold and damp air, indi- 
gestion, constipation or the inhalation of substances such as the pollen 
of certain plants, especially rag-weed, golden-rod and roses. Contact 
with animals, especially horses, cats and dogs may also initiate an attack. 
It has been recently shown, by Schloss and Talbot particularly, that 
certain foods, especially eggs and rarely milk, pork and other meats 
are responsible for attacks in certain children. There can be no doubt 
that this susceptibility to the pollen of plants, to contact with animals 
and to various foods is a phenomenon closely allied to that of anaphylaxis. 
Cutaneous and intracutaneous tests have shown not only the production 
of urticarial wheals, at the site of the test, but have also initiated attacks 
of asthma. In certain instances the susceptibility to these protein sub- 
stances is inherited ; in others it is perhaps the result of an active sensiti- 
zation, but in many instances there is no sufficient explanation as to how 
the child has become sensitized. The constriction of the bronchi, which 
causes many of the symptoms of asthma, is probably chiefly due to the 
contraction of the unstriped circular muscular fibers in the walls of the 
bronchi. Swelling of the mucous membrane, either by dilatation of the 
blood vessels or by exudation of the serum into the mucous membrane 
itself undoubtedly is a factor of importance in some instances. 

Symptoms. — Four quite distinct clinical types of asthma are seen in 
children: (1) Cases which in their onset simulate attacks of bronchitis; 
(2) those in which asthmatic symptoms follow an attack of bronchitis, 
continuing for weeks or months, but not necessarily recurring; ()>) 
hay fever, or the periodical form which occurs every summer; (-4) that 
which resembles the ordinary adult asthma, with the nervous element 
predominating. The prominence of the catarrhal symptoms is char- 



ASTHMA 489 

acteristic of all forms of asthma in children, the first two varieties 
mentioned being peculiar to early life. 

Attacks Resembling Acute Bronchitis. — These cases are rare, but 
may be seen even in infants. The onset is sudden, with moderate fever, 
incessant cough, severe dyspnea, and sometimes cyanosis, prostration, 
and cold extremities. The chest is filled with sonorous, sibilant, and 
soon with subcrepitant rales. Instead of running the usual course of 
bronchitis of the finer tubes, the symptoms may pass away very rapidly, 
and in forty-eight, sometimes in. twenty-four, hours the patient may be 
quite well. It is only by the course of the disease and by recurring at- 
tacks that their true nature can be recognized. In infants this form of 
asthma may be fatal. 

Cases Following Attacks of Bronchitis — Catarrhal Asthma. — This 
form is not uncommon, though it is frequently designated by some other 
term than asthma — sometimes as spasmodic bronchitis, or catarrhal 
spasm of the bronchi. The symptoms are, however, indistinguishable 
from asthma, and they evidently belong in the same category. This 
form is usually seen in infants, being rare after the third year. Many 
of the patients are rachitic; others have large tonsils, or adenoid growths 
of the pharynx; while in still others there is every reason to suspect 
the presence of large bronchial glands. Usually there is nothing pecu- 
liar about the antecedent bronchitis; in most cases it is not especially 
severe, and is limited to the larger tubes. The febrile symptoms subside 
in a few days, but the cough continues, as do also the dyspnea and 
wheezing. When the symptoms are fairly established they are very 
uniform and characteristic. The respiration is accelerated, usually 
to 50 or 60, sometimes to 70 or (SO, a minute. The temperature from 
time to time may be very slightly elevated, or it may remain normal. 
The respiration is noisy, labored, and accompanied by distinct wheel- 
ing. 

On auscultation, there is prolonged expiration accompanied by loud. 
wheezing and sonorous, or sibilant rales, and occasionally coarse moisi 
rales are heard. In cases which have lasted some time a moderate amount 
of emphysema, can be inferred from the prominence of the infraclavicular 
regions, and exaggerated resonance over the chest in front and the de- 
pression of the bases posteriorly. 

These symptoms and signs often continue for three or four weeks. 
While they are constantly present, they vary in intensity from time to 
time, being usually much worse at night. The symptoms are ah 
increased by exposure to a cold, damp atmosphere, by any fresh ac 
sion of bronchitis, and often by trivia] digestive disturbances. The cough 
is not usually severe, ami expectoration in mosl - absent The 

general health Is often hut little affected. With recovery from the asth 



490 DISEASES OF THE RESPIRATORY SYSTEM 

matic symptoms the emphysema usually disappears gradually, although 
we have seen severe cases in which it persisted. 

What proportion of these children afterward develop ordinary asthma, 
we are unable from personal experience to say. Some undoubtedly do, 
but in others which we have been able to follow, recovery has seemed to 
be permanent. This would appear more likely in those cases closely 
associated with rickets, or with other causes which disappear spontane- 
ously with time or as a result of treatment. v 

Hay Fever. — This is very rare before the seventh year and but few 
well-marked cases are seen before the tenth year. In its clinical aspects 
it does not differ essentially from the disease as seen in adults, except 
possibly by the greater prominence of the bronchial catarrh. 

Ordinary Attacks of the Adult Type. — These usually occur at inter- 
vals of a few weeks or months, depending upon the nature of the excit- 
ing cause. The beginning is usually at night with dyspnea, a short, dry 
cough, and loud, wheezing respiration. Deep recession of the soft parts 
of the chest is seen, as in laryngeal stenosis. There is prolonged expira- 
tion, accompanied by loud, sonorous, sibilant and wheezing rales, and 
the vesicular murmur is very feeble. Later, moist rales may be heard. 
After many attacks emphysema is present. This occurs more rapidly 
than in adults, and may be extreme, giving rise in marked cases to 
serious thoracic deformity. On account of the loss of sleep and interfer- 
ence with nutrition, the general health may become seriously impaired. 
Urticarial wheals are not infrequently present at some time during an 
attack. 

Diagnosis. — Typical attacks of asthma are easily recognized. Some 
of the catarrhal forms seen in infancy, however, present some difficulty, 
and a positive diagnosis may be impossible except by the progress of the 
case. The presence of urticaria speaks strongly for asthma. The blood 
picture in asthma is characteristic and of much value in diagnosis. 
The important thing is the presence of a large number of eosinophile 
cells. They may form as high as 15 to 20 per cent of the leucocytes. 
In a series of cases examined in one of our clinics by Wile, the average 
was 10.7 per cent; the highest observed being 26 per cent. The eosino- 
philia is greatest at the height of the attack. The blood examination 
serves to differentiate asthma from simple bronchitis and from tubercu- 
losis. The existence of marked eosinophilia definitely establishes the 
asthmatic character of some of these attacks in infancy. Eosinophile 
cells are commonly found in the sputum. Charcot-Leyden crystals and 
Curschmann's spirals may also be seen but much less frequently and 
usually only in the sputum of older children. 

Prognosis. — This is best in the cases of catarrhal asthma in infants, 
and in older patients when it depends upon some local cause which can 



ASTHMA 491 

be removed, as when the disease is due to reflex nasal or pharyngeal 
irritation. In the majority of other cases, asthma is likely to become 
chronic unless the child is removed to some climate in which the attacks 
do not occur. The younger the child, the shorter the duration of the 
disease, and the less marked the hereditary tendency, the better the 
prognosis. In those children that are sensitive to the pollen of plants 
and to certain foods there is reason to believe that specific treatment by 
immunization may be of benefit. The results with hay fever have been 
encouraging and Talbot was able to prevent, or diminish greatly, the 
attacks in some of his patients especially those who were sensitive to 

egg- 

Treatment. — The nose and the rhinopharynx should be carefully 
examined in every case of asthma, and any pathological condition there 
present should receive attention as the first step in the treatment. Im- 
portance, in children, should be attached to the removal of adenoid 
growths of the pharynx. We must admit, however, to have seen very 
few cases of asthma cured or even greatly improved by this means. 
During attacks, the best means of relieving the symptoms is the inhalation 
of fumes of nitre paper or stramonium leaves. Most of the proprietary 
remedies contain these ingredients. The sleeping room may be filled with 
the fumes of these substances, or the child may be placed in a tent into 
which the fumes are introduced. Emetics may be employed when the 
attack is brought on by indigestion. To prevent the recurrence of nighl 
attacks, antipyrin is valuable given in full doses at bedtime — four grains 
at five years and six grains at ten years. Between the attacks the syrup 
of hydriodic acid (for a child of five years one-half teaspoonful, t.i.d.) 
or potassium iodid (gr. ii to gr. iv, t.i.d.), may be given for a number 
of weeks. Tonics are often useful. Those especially valuable in asth- 
matic patients are cinchonidia (gr. ii, t.i.d.) and arsenic (gr. 1-100, 
t.i.d.). They may be advantageously combined. Cocain used locally 
in the throat and opium by mouth or hypodermieally will often cause 
a cessation of attacks but are objectionable with older children on ac- 
count of the tendency to the formation of a drug habit. On account of 
their susceptibility to the drug, cocain is dangerous with infant- and 
very young children. 

In the severe acute attacks nothing gives so much immediate relief as 
the use of epinephrin Lntramuscularlj dose *H,v to "Iviii. for a child of 
three years. 

In the cases of catarrhal asthma following bronchitis, expectorants 
and ordinary cough remedies are useless. Cod-liver oil and the iodid of 
potassium are valuable in some of the cases. Others atly relieved 

by the regular use of creosote inhalations several times a day. with a 
nightly dose of antipyrin. The fumes of nitre and stramonium often 



492 DISEASES OF THE RESPIRATORY SYSTEM 

afford no relief, and sometimes the cases are made distinctly worse by 
them. The best of all measures is to send the child at once to a warm, 
dry climate. 

Very careful attention should be given to the diet; articles to be 
avoided with most asthmatic children are cream, eggs, and all sweets. 
For all children who have had repeated attacks, whether in the form 
of hay fever or for those whose asthma is chiefly in the winter and spring 
and excited by attacks of bronchitis, the most important thing is re- 
moval to a place where they do not have the disease, and a residence 
there long enough to break up the tendency to recurrence. This will 
usually require several years. The region best suited to most asthmatics 
is one which is high, dry, and moderately warm. Some do exceedingly 
well at the seashore; others much better in the mountains. Patients 
often suffer less in cities than in the country. 

Children who are susceptible to the odor of animals should be kept 
from contact with them. Those who are sensitive to proteins of certain 
foods should have these eliminated from the diet after it has been de- 
termined which are the proteins responsible. Immunization by the in- 
gestion of very small quantities of the proteins has been practiced by 
Schloss and Talbot with marked success in some instances. The method 
is still in the experimental stage and should be employed with caution. 

Those children who are sensitive to pollen should spend the weeks in 
which the plants are in bloom in the mountains or at some place where 
they are not exposed. Distinct benefit has been obtained by immuniza- 
tion against pollen in the hay fever and asthma of adults. It is as yet too 
early to say what the effect of this form of treatment will be with chil- 
dren. It should be attempted only by one trained in the methods of 
immunity. 



CHAPTER IV 

DISEASES OF THE LUNG&— (Continued) 

PNEUMONIA 

In early life the lungs are more frequently the seat of organic disease 
than any other organs in the body. Pneumonia is very common as a 
primary disease, and ranks first as a complication of the various forms 
of acute infectious disease of children. It is one of the largest factors 
in the mortality of infancy and childhood. 



PNEUMONIA 



493 



Cases of acute pneumonia are divided, from an anatomical point of 
view, into two principal groups: (1) bronchopneumonia, also known as 
catarrhal and as lobular pneumonia; (2) lobar pneumonia, also known 
as croupous and as fibrinous pneumonia. These differ little from each 
other in etiology, but considerably in the products of inflammation, the 
distribution of the disease in the lung, and somewhat as to the parts 
involved and the nature of the changes in them. 



\ 



• ♦♦Jr. , 



Fig. 46. — Bronchopneumonia. The picture shows at its center one entire air vesicle, 
and at its margin parts of four or five other vesicles; they are filled with large epi- 
thelial cells having small nuclei. There are also seen leucocytes with intensely 
black nuclei and narrow protoplasm. Between the cells is a finely granular ma- 
terial, which is the exudation fluid coagulated during the hardening process. The 
alveolar septa are somewhat infiltrated. — Prom Karg and Schmorl. 

In bronchopneumonia the large bronchi are the seal of a superficial 
inflammation, while in those of small size the entire bronchial wall is 

affected; the exudation into the air vesicles is mainly cellular, being 
made up of epithelial cells, leucocytes, and red blood-cells (Fig. 16), 
fibrin being either absent, or present only in small amount. In many 
cases there are marked changes both in the alveolar septa and in the 
interstitial tissue of the lung; resolution is often imperfect, and there 
is a strong tendency for the inflammation to pass into a chronic form, 
involving the connective-tissue framework of the luiiL r . The Lesion ifl 
widely and often irregularly distributed, usually being mosi marked in 



494 



DISEASES OF THE RESPIRATORY SYSTEM 



the vicinity of the small bronchi from which the inflammation spreads, 
and in the most superficial lobules of the lung. 

In lobar pneumonia, bronchitis, when present, is usually superficial, 
the walls of the bronchi being very slightly or not at all affected; the 
same is true of the alveolar septa. The principal product of the inflam- 
mation is fibrin (Fig. 47), which fills the alveoli and the terminal bron- 
chi, the cells being relatively few and chiefly leucocytes. The process is 




Fig. 47. — Lobar Pneumonia. In the air vesicle shown in the picture there is a firm, 
close network of fibrin, in the meshes of which are leucocytes. At the lower part the 
exudation has contracted away from the wall in consequence of the process of hard- 
ening. — From Karg and Schmorl. 



usually sharply circumscribed, involving an entire lobe or a part of a 
lobe. In most cases it clears up rapidly and completely, there being but 
little tendency to involve the framework of the lung in a chronic process. 
While in typical cases the two forms of inflammation are quite dis- 
tinct, there are seen many intermediate forms which partake of the char- 
acters of both, and one may be in doubt, even after a microscopical ex- 
aniination, in which group to place a case. It not infrequently happens 
that both varieties of pneumonia are present in different parts of the 
same lung or in both lungs at the same time. These mixed forms are 
especially frequent during the second and third years; but during the 
first year, and after the third, the types are usually well marked. 



Six to twelve " 


u 


96 


Second year, 


a 


73 


Third 


a 


19 


Fourth " 


a 






• PNEUMONIA 495 

The following table shows the relative frequency of lobar and broncho- 
pneumonia in thr,ee hundred and seventy cases. 1 nearly all taken from 
one institution (Xew York Infant Asylum). They include all the a 
of acute primary pneumonia occurring during seven years: 

Under six months, bronchopneumonia, 73 cases; lobar pneumonia, 11 cases 

" " 29 ■ 

40 " 

« « q u 

Totals, " 261 " « " 109 ■ 

Thus it will be seen that, of the cases of acute pneumonia occurring 
during the first two years, twenty-five per cent were lobar and seventy- 
five per cent were bronchopneumonia. 

When we come to a consideration of the microorganisms with which 
the different forms of pneumonia are associated, we find that they do 
not correspond to the anatomical varieties. Lobar pneumonia is regu- 
larly associated with the presence of the pneumococcus, rarely with Fried- 
lander's bacillus, but in a large number of cases other organisms are 
also found. In bronchopneumonia there is almost always a mixed infec- 
tion. In the primary cases the pneumococcus is usually the predominant 
organism, but it is commonly associated with the staphylococcus aureus. 
In the secondary cases, especially when pneumonia follows measles or 
scarlet fever, the streptococcus is usually present, such cases being gen- 
erally of a severe type. In the pneumonia of diphtheria, besides the 
streptococcus the diphtheria bacillus is frequently found. In winter the 
bacillus of influenza may be the only organism present, but it is usually 
associated with the pneumococcus. The organisms mentioned are found 
in all possible combinations, sometimes one and sometimes another pre- 
dominating. With any of them the bacillus of tuberculosis may be 
found. 

Much interest has recently been aroused in the different typ 
pneumococci which are found in acute pneumonia. 2 Of the cases Btudied 
thus far in young children, type iv of Cole's classification, has been 
much the most frequently present; but all the forms found in adults 
have been observed. In a series of 50 cases studied at the Babies 5 I 
pital nearly 75 per cent were type iv. 



a The division was here made according to the predominant clinical or patho- 
logical features. Most of the doubtful cases were classed as bronchopneumonia. 

2 According to the researches of Cole of the Rockefeller [nstitute pneu- 
mococci may be divided into four groups or types. Nos. i. n and m have definite 
individual characteristics; iv includes the remainder or unci group. The 

differentiation is made by animal inoculation and require* Fro twelve to 
twenty-four hours. For type i he has produced a Berum from immunised 



496 



DISEASES OF THE RESPIRATORY SYSTEM 



Some idea of the nature of the infection in pneumonia may be 
gained from the following table. The sputum cultures represent the 
pneumonias of one winter and spring in the Babies' Hospital, and the 
post-mortem cultures from those of two seasons in the same institution : 



Sputum cultures from 124 
cases of pneumonia. 



Post-mortem cultures from the 
lungs in 76 cases of pneumonia. 



Staphylococcus aureus 

Pneumococcus 

Streptococcus 

Bacillus influenzae 



in 116 cases 

" 94 " 

" 63 " 
" 47 « 



36 (alone in 8) 
26 ( " " 4) 
17 ( " " 1) 
19 ( " " 2) 



Why the same exciting cause in one case produces bronchopneumonia, 
and in another lobar pneumonia may be in part owing to the difference 
in the structure of the lung at the different ages; especially the relatively 
large size of the bronchi in infancy. Again, in very young and in feeble 
children, the process tends to become diffuse and the products are chiefly 
cellular; in those who are older and more vigorous it is likely to be 
circumscribed, with fibrin as its chief product; in the intermediate ages 
and intermediate conditions the types are often mingled. 

The immediate source of infection of the lungs is the mouth or the 
rhinopharynx. All the forms of bacteria found in pneumonia may be 
found in these cavities, some of them constantly, others only at certain 
times, especially during an attack of any of the acute infectious diseases. 
Provided the other conditions are favorable, pneumonia may be excited 
by direct contagion. This plays a small part in inducing primary pneu- 
monia ; there seems, however, to be little doubt that the secondary forms, 
especially the pneumonia complicating measles, diphtheria and influenza, 
are not infrequently communicated in this way. 



which has been shown to have distinctly curative effects. Thus far no satis- 
factory serum for the other groups has been produced. As the serum is not 
effective in infections due to other types than i, it is of little assistance in 
the pneumonias of young children since few of the cases of pneumonia at this 
age are due to this type of organism. The serum is not yet available for 
general use. 

The pneumococci of types i and n are seldom found except in the mouths 
of persons suffering from pneumonia or those in contact with them. Type 
iv is the form which is most widely diffused and is frequently found in the 
mouths of healthy persons. The pneumonia associated with type iv in adults 
is usually of the mildest variety seen. The fact that this is the type of or- 
ganism usually found in the pneumonias of children probably accounts for the 
low mortality from primary pneumonia in patients over two years of age. In 
infants and young children, however, pneumonia associated with type iv may 
be very severe. 



ACUTE BRONCHOPNEUMONIA 497 

The different forms of pneumonia which will be considered are: (1) 
Acute bronchopneumonia ; (2) acute lobar pneumonia ; (3) acute pleuro- 
pneumonia; (4) hypostatic pneumonia; (5) chronic bronchopneumonia. 

Tuberculous bronchopneumonia will be discussed in the chapter 
devoted to Tuberculosis. 



ACUTE BRONCHOPNEUMONIA 
(Catarrhal Pneumonia; Lobular Pneumonia; Capillary Bronchitis) 

This is essentially the pneumonia of infancy. Under two years, the 
great majority of the cases of primary pneumonia are of this variety, and 
throughout childhood nearly all the cases of secondary pneumonia. The 
term bronchopneumonia describes a lesion rather than a disease, several 
quite distinct forms of infection being included under this head. Its 
mortality is high, because of the tender age of the patients in which the 
primary cases occur, and also because when secondary it complicates the 
most severe forms of the acute infectious diseases of children. 

Etiology. — The distribution, according to age, of 426 cases of 
bronchopneumonia was as follows: 

During the first year 224 cases, or 53 per cent. 

" second year 142 " u 33 u u 

" third " 46 ■ "11 " " 

" fourth " 10 " " 2 " " 

" fifth " 4 " " 1 « ■ 

426 100 

After four years bronchopneumonia is infrequent as a primary dis- 
ease, although it is seen throughout childhood as a complication of the 
infectious diseases. 

Of the cases referred to, 38 per cent occurred during the winter 
months, 31 per cent during the spring, 13 per ceni during the summer, 
and 18 per cent during the autumn. While, therefore. Dearly 70 per ceni 
of the cases occurred in the cold months, bronchopneumonia is seen 
throughout the year. 

Bronchopneumonia, affects all classes, but is most frequeni in chil- 
dren having poor hygienic surroundings, especially in inmates of institu- 
tions, and in those previously debilitated by constitutional or local dis 
ease. In 246 consecutive cases of primary pneumonia, 110 were in L r "«><l 
condition prior to the attack, and 126 were delicate, rachitic, or syphilitic. 

The following table gives a good idea of the conditions with winch 
acute bronchopneumonia is most frequently sen ; I I", cases were dai 
as follows : 



498 DISEASES OF THE RESPIRATORY SYSTEM 

Primary x 164 

Secondary to bronchitis of the large tubes 41 

Complicating measles 89 

pertussis 66 

diphtheria 47 

acute ileocolitis 19 

scarlet fever 7 

influenza 6 

" varicella 2 

" erysipelas . ; 2 

443 

A large number of the patients had previously suffered from one or 
more attacks of bronchitis, and fifteen previously had bronchopneumonia. 

As an exciting cause, exposure to cold must still be classed among the 
potent factors of primary pneumonia. The organisms concerned in 
bronchopneumonia have been discussed in the previous pages. 

Lesions. — The term bronchopneumonia is now generally adopted as 
a generic one, and it is to be preferred either to lobular or catarrhal 
pneumonia, as it gives prominence to the bronchial element in the inflam- 
mation. The process may begin in the larger tubes and gradually extend 
to those of smaller caliber, finally involving the pulmonary lobules in 
which these tubes terminate; or it may extend to the air vesicles which 
surround the tube in its course through the lung, so that in whatever 
direction the lung is cut, there are seen, surrounding the small bronchi, 
zones of pneumonia (Fig. 48). In other cases the process seems to begin 
almost at the same time in the small bronchi and the air vesicles, as both 
are found involved, even when death occurs within a few hours of the 
first symptoms. 

There are, however, cases in which the parts of the lung affected 
bear no relation to the bronchi— where there are found simply smaller 
or larger areas of pneumonia irregularly scattered through the lung, 
usually near the surface (Plate VIII). From the distribution of the 
lesions such cases might better be termed lobular than bronchopneu- 
monia. 

Much has been said in the past about pulmonary collapse from ob- 
struction of the small bronchi, as a condition antecedent to this form of 
pulmonary inflammation. So far as our observations go, there has 
been adduced but little evidence that this is the rule, or, indeed, that it 
often occurs. Even in autopsies made very early in the disease, but little 
collapse is found, most of the cases supporting the view of Delafield, that 
when the disease extends from the bronchi to the air cells it involves 
those surrounding the tube quite as regularly as those to which the tube 
leads. 

1 It is probable that a number of cases complicating influenza were included 
among these primary cases. 



PLATE VIII 












Act i i Bronchopnei moni \ 
Primary pneumonia in a child two years old, showing the irregular distribution ol 
the consolidation and its incomplete character. \ is the pleura somewhal thickened 
B, lung tissue which is practically oormal; CC are consolidate rttered through 

which are groups of air vesicles still containing air. (Slightly magnrai 



ACUTE BRONCHOPNEUMONIA 



499 



The following observations are made from a study of 170 autopsies of 
which we have records, microscopical examinations having been made in 
about one-third of the number. 

Seat of the Disease. — In eighty-two per cent of the autopsies extensive 




Fig 48.— Bronchopneumonia, with Thickening of a Bronchus. In the cent* 

the picture is seen a small bronchus, B, which is cut somewhat obliquely; the degree 
to which its wall, C, is thickened is well shown. It is partially filled with pua, its 
mucous membrane is nearly destroyed, and its walls greatly thickened from infiltra- 
tion with leucocytes. This infiltration extends to the lung tissue in the neighbor- 
hood: it forms a peri-bronchitic zone of pneumonia. Elsewhere in the picture tne 
lung tissue, A, is practically normal. D is a small blood-vessel. E is anol her smaller 
bronchus. Throughout the lung everywhere accompanying the small bronchi similar 
changes were seen, in addition to which there were present some large areas* . con- 
solidation. The disease was of four and a half weeks duration; the ohild, Bn 
months old. 



disease was found in both lungs. The parts most affected v , »wer 

lobes posteriorly; next to this the posterior pari of both t 
lower lobes. 



The left lower lobe was more extensively diseased than the 



500 DISEASES OF THE RESPIRATORY SYSTEM 

right in over two-thirds of the cases. If the pneumonia is in front only, 
the right apex is the most frequent seat. 

There are a certain number of cases which appear to follow tolerably 
well-defined stages of congestion, consolidation, and resolution; but the 
disease may be arrested at any of the stages and the child recover, or 
death may occur at any stage and there may be found at autopsy differ- 
ent portions of the lung representing all the stages mentioned. In con- 
sidering, therefore, the lesions of bronchopneumonia, it seems best to 
describe the condition in which the lungs are found at the various periods 
when death is likely to occur, rather than to attempt to describe the 
different stages of the disease, as in lobar pneumonia. 

1. The Acute Congestive Form (Acute Red Pneumonia). — This is 
the condition in which the lung is usually found if death occurs during 
the first two or three days of the disease. In the cases severe enough to 
cause death in the first twenty-four hours, very little can be seen by the 
naked eye except acute congestion. The vessels of the pleura are dis- 
tended, and there may be small superficial hemorrhages. Both lower 
lobes are usually heavy and dark colored. There is to the naked eye 
no consolidation. All, or nearly all, the lung can be inflated. On sec- 
tion, there is found intense congestion with some edema. When the 
process has lasted a little longer the affected areas are more sharply 
defined. These, usually the posterior portions of both lungs, are of a 
brownish-red color, and appear partially consolidated, although with 
a little force they may in most cases be inflated. After section, pus and 
mucus flow from the divided bronchi, and the whole lung may be more 
or less congested or edematous. 

The microscope alone reveals the fact that these are not cases of sim- 
ple pulmonary congestion or bronchitis of the finer tubes. In one case 
in which death occurred twelve hours from the first symptoms, well- 
marked evidences of inflammation of the air vesicles were found. In 
these hyper-acute cases, the microscope shows great distention of all the 
small blood-vessels of the affected area, and small or large extravasations 
of blood just beneath the pleura, into the alveoli and interstitial tissue of 
the lung. In some cases these hemorrhages form the most striking feature 
of the lesion. The air vesicles are partially, some almost completely, 
filled with red blood-cells, swollen and desquamated epithelial cells, and 
a few leucocytes (Fig. 46). The red blood-cells predominate. The in- 
flammation may be diffuse, involving nearly a whole lobe, or in small 
areas in the neighborhood of the small bronchi. The mucous mem- 
brane of the large and small bronchi is the seat of catarrhal inflamma- 
tion, and the walls of the latter are infiltrated with round cells. 

When the process has lasted from twenty-four to forty-eight hours 
all the changes described are more marked, but the red color of the 



ACUTE BRONCHOPNEUMONIA 



501 



inflammatory products still persists. Such cases give during life only 
the signs of congestion and bronchitis. 

2. The Mottled, Red and Gray Pneumonia. — This is the usual ap- 
pearance when the disease has lasted somewhat longer, and is found in 
most of the cases dying between the fourth and fourteenth days. There 
are usually at this time quite large areas of consolidation, sometimes 
affecting nearly an entire lobe, so that at first sight the case may resemble 




Fig. 49. — Acute Bronchopneumonia. In the center is shown a small bronchus, B, 
with a zone of pneumonia about it. The greater part of the section is made up of 
emphysematous lung tissue, E E, showing dilatation of the alveolar spaces and rup- 
ture of some of the alveolar septa. At the border, AAA, are seen the margins of 
consolidated areas of lung. 



lobar pneumonia. This is sometimes described as the "pseudo-lobar" 
form. The extent of these areas depends largely upon the duration of 
the disease. Jn most cases there is pleurisy over the consolidated por- 
tions. This may cause the lung to adhere to the chest wall, the firmness 
of the adhesions depending upon the duration of the process. The sur- 
face of the lung is usually of a mottled red and gray color; it often has 
a coarsely granular feel, due to the consolidation of some of the super- 
ficial lobules of the lung. On section, it is rarely found that an entire 
lobe is consolidated, the superficial portion being most affected, while 



502 DISEASES OF THE RESPIRATORY SYSTEM 

the central part is normal or only congested. The color is mottled, like 
that of the surface. In some places the consolidation appears complete; 
in others the consolidated areas are separated by healthy, congested, or 
emphysematous lung tissue (Fig. 49). The gray areas surround the 
small bronchi and vary in size. The smallest ones look very much like 




Fig. 50. — Bronchopneumonia. Dense infiltration of pus cells in and about a small 
bronchus; under a low power. The cavity shown in the specimen is a cross-section 
of one of the small bronchi, which is partially filled with pus cells; the epithelium is 
destroyed. The bronchial wall and the pulmonary tissue in the neighborhood are so 
densely infiltrated with leucocytes that almost every trace of normal structure is 
effaced. Child fifteen months old, disease of four weeks' duration. Extensive areas 
like this were found in both lungs. 

miliary tubercles. The larger ones are seen where the process has existed 
for a longer time and has gradually invaded the contiguous air cells. If 
the lung is cut parallel with the bronchi, there may be seen small gray 
striae of pneumonia along their course (Fig. 48, C). From the cut 
bronchi, pus flows quite freely on pressure. The bronchial walls are 
often seen to be thickened even by the naked eye. The parts affected 



ACUTE BRONCHOPNEUMONIA 503 

are usually the posterior portions of the lower lobe of one or both sides, 
the remainder of the lobes being congested or edematous, while in front 
the lung is emphysematous. 

Under the microscope the smaller bronchi (Fig. 48) are seen to be 
much thickened and infiltrated with leucocytes. The gray areas sur- 
rounding the bronchi are made up of groups of air vesicles, which are 
packed with leucocytes (Fig. 50). Fibrin is sometimes seen in small 
amount, also red blood-cells and desquamated epithelial cells, but the 
leucocytes predominate. Surrounding the areas densely infiltrated are 
groups of air vesicles which are normal or congested, or which show 
only the earlier stages of the inflammatory process. 

3. Gray Pneumonia (Persistent Bronchopneumonia) . — This form is 
seen in protracted cases when there have been continuous symptoms 
usually for from three to six weeks. The pleuritic adhesions are more 
general and firmer. The amount of lung involved may be very great, 
often nearly the whole of both lungs posteriorly. The affected lung ap- 
pears completely consolidated and slightly enlarged. On section, it is 
of a nearly uniform gray color, sometimes of a yellowish-gray. On 
pressure, pus exudes from the smaller and larger bronchi. The bronchial 
walls are markedly thickened, and in some places there may be a slight 
dilatation of the smaller bronchi. The part of the lung not consolidated 
may be almost white, owing to vesicular emphysema. In some cases 
there is also interstitial emphysema. Small cavities containing pus may 
be found in the lung. The bronchial glands are frequently swollen to 
the size of a large bean, and are of a reddish-gray color. 

The microscope shows that the air vesicles of the consolidated por- 
tions are distended chiefly with leucocytes, but there are also epithelial 
and connective-tissue cells. The alveolar septa may be so much thick- 
ened as to encroach upon the alveolar spaces (Fig. 51). Complete reso- 
lution is then impossible. 

Termination. — Death may occur at any stage, or the pathological 
process may be arrested at any stage and the case go on to recovery. 
Resolution may take place before any consolidation recognizable by physi- 
cal signs has occurred; in such cases it is usually rapid and complete. 
If there has been consolidation, resolution may take place after two or 
three weeks and be complete, or it may be delayed for five or six weeks 
and still be complete. In many cases, especially those in which it is 
delayed, resolution is only partial, and there are relapses or recurring 
attacks. After the first, or after several attacks, there may develop a 
chronic interstitial pneumonia; or simple pneumonia may be followed 
by tuberculosis. Such cases as these are to be carefully distinguished 
from the much more frequent ones in which the bronchopneumonia is 
tuberculous from the outset. 



504 



DISEASES OF THE RESPIRATORY SYSTEM 



Associated Lesions of the Lungs. — Pleurisy is almost invariably 
found over every large area of consolidation, and in cases of more than 
three or four days' duration; while in most of those fatal within the 
first few days the pleura is normal or only congested. It is seen in 
all grades of severity, from a slight gray film of fibrin that can hardly 
be stripped off, to a yellowish-green exudation one-fourth of an inch 




Fig. 51. — Persistent Bronchopneumonia; Highly Magnified. There is shown at 
A A marked thickening of the alveolar septa, encroaching upon the alveolar spaces. 
All the alveoli, B B, are densely packed with leucocytes. A similar condition also 
through nearly the whole of the affected lung. (For history and temperature, see 
Fig. 60.) 



thick. A small amount of serum — two or three ounces — in the pleural sac 
is common, but a large serous effusion is very rare. Cases in which there 
is an excessive inflammation of the pleura are considered elsewhere 
under the head of Pleuropneumonia. Empyema occurs both during the 
stage of acute inflammation of the lung and while this is subsiding, 
but it is less frequent than in lobar pneumonia. 

Bronchial Glands. — In all the recent acute cases these are .swollen 



ACUTE BRONCHOPNEUMONIA 505 

and red; the usual size is that of a pea or a bean. The}' show micro- 
scopically the usual changes of acute hyperplasia. In protracted cases, 
and after repeated attacks, they may be two or three times the size 
mentioned, and of a gray color. It is rare that they are large enough 
to give rise to symptoms unless they become the seat of tuberculous 
deposits. 

Emphysema. — This is one of the regular and striking features of 
acute brochopneumonia in infancy, it being especially marked in the 
protracted cases. It is usually vesicular, involving the greater part of 
the upper lobes in front and the anterior margin of the lower lobes. Oc- 
casionally interstitial emphysema is seen, forming either large striae 
upon the surface of the lung, or blebs of considerable size along the 
anterior margin. This may occur even in cases uncomplicated by per- 
tussis or by laryngeal stenosis. 

Gangrene. — Gangrenous areas were found in six cases of the series 
mentioned. In four of these the pneumonia was primary, in one it 
followed diphtheria, and in one ileocolitis. It occurred in scattered areas 
of a grayish-green color, varying from one-fourth of an inch to two 
inches in diameter. 

Abscesses of the lung are by no means uncommon. They were noted 
in seven per cent of the autopsies. They are usually minute and mul- 
tiple, varying in size from one-sixth to one-half inch in diameter. Some- 
times a portion of a lobe is fairly honeycombed with minute abscesses. 
In one case a large abscess was found 'occupying the greater part of a 
lobe, the symptoms resembling those of empyema. Abscesses are usually 
found in regions where the inflammatory process has been especially 
intense. They may be found in prolonged cases, in those of unusual 
severity, as shown by excessively high temperature and rapid extension 
of the disease, and in very delicate subjects. The microscope shows that 
these abscesses usually begin as an accumulation of pus in the small 
bronchi, whose walls become softened and break down on account of the 
intensity of the inflammation. They may be superficial, but are more 
commonly in the interior of the lung; they contain yellow pus and 
sometimes broken-down lung tissue. Small abscesses can not be recog- 
nized clinically; the large ones give the symptoms and signs of em- 
pyema. They arc discussed more fully elsewhere. In several instances 
they have been successfully operated on, though wrongly diagnosticated. 

The lesions in other organs will be considered under Complications. 

Symptoms. — Bronchopneumonia has no typical course. The cases 
differ from each, other very markedly, but they may be divided into a 
few quite distinct groups. 

1. The Acute Congestive Type. — This may be seen at any age, but 
is more frequent in young infants. It may be either primary or sec- 



506 DISEASES OF THE RESPIRATORY SYSTEM 

ondary, being not uncommon in either form. Its symptoms are few and 
irregular, and the disease is often unrecognized. The entire duration 
may be only twenty-four hours. High temperature, extreme prostration, 
cyanosis, and rapid respiration may be the only symptoms. The tem- 
perature varies between 104° and 107° F., usually rising steadily until 
death occurs. The prostration is extreme from the outset, the patient 
being overwhelmed by the suddenness and severity of the attack. 
Cyanosis is frequently present, and is almost always seen shortly before 
death. The respirations are from 60 to 80 a minute, but in most cases 
not strikingly labored. Cough is frequently absent. Cerebral symptoms 
are often marked — dulness and apathy, sometimes quite profound stupor, 
and not infrequently convulsions just before death. The physical signs 
are few and inconclusive. There is often nothing abnormal except very 
rude breathing over both lungs behind ; sometimes the breathing on one 
side is feeble, and on the other much exaggerated. There may be no 
rales whatever, and no change in the percussion note. 

The suddenness and severity of these symptoms are something which 
it is hard for one who has not observed them to appreciate. We have 
known an infant to die in twelve hours from the time in which he was 
apparently in perfect health, and had an opportunity to confirm the 
diagnosis of pneumonia by a microscopical examination of the lung. 
The diagnosis can not be positively made during life, and in most of the 
cases the disease passes under some other name. It is often regarded as 
malignant scarlet fever or measles with suppressed eruption, or cerebro- 
spinal meningitis. 

If the children are sufficiently strong to withstand the onset of vio- 
lent symptoms, they may recover completely in four or five days, the 
lung clearing up very rapidly. In other cases these grave symptoms may 
abate in a day or two, to be followed by those of ordinary broncho- 
pneumonia, which runs its usual course. 

The symptoms of some of these cases may be explained by the sudden 
intense engorgement of the lung, which, owing to the small size of the 
air vesicles, interferes with its function almost as much as does consoli- 
dation. In other cases the symptoms are due not so much to the pul- 
monary condition as to a general pneumococcus infection. We have 
seen cases of pneumonia fatal in less than two days in which the pneu- 
mococcus was found by post mortem cultures to be disseminated through 
the organs of the body. 

2. Acute Disseminated Bronchopneumonia (Capillary Bron- 
chitis). — Although the symptoms in this class of cases are chiefly due 
to the bronchitis, there are always evidences of pneumonia to be found 
post mortem. These are not very common cases. The process begins 
as an inflammation of the medium-sized and small bronchi, but not of 



ACUTE BRONCHOPNEUMONIA 507 

the finest bronchi. The onset is acute, with fever, very rapid and labored 
breathing, severe cough, moderate prostration, and in most cases 
cyanosis. 

The temperature is not high, usually only from 100° to 102° F., and 
it often continues so for three or four days. The pulse is rapid, and at 
first is full and strong. The respirations are exceedingly rapid, often 
from 80 to 100 a minute. There is dyspnea with marked recession of 
all the soft parts of the chest during inspiration. Cough is always pres- 
ent, usually severe, and sometimes almost incessant. The prostration is 
not so great as in the cases previously described, and the development 
of the symptoms is much less rapid. 

There are at first sibilant and afterward subcrepitant rales over the 
entire chest, with which are usually mingled coarser moist rales. There 
are no evidences of consolidation. The respiratory murmur is every- 
where feeble, but not otherwise altered. Percussion generally gives ex- 
aggerated resonance, owing to the emphysema which is present, the note 
being sometimes almost tympanitic. 

The symptoms may gradually increase in severity until death takes 
place by the third or fourth day, from respiratory or cardiac failure. 
There is usually marked cyanosis, and toward the end rapidly increasing 
prostration. Just before death the temperature often rises rapidly to 
106° or 107° F. At the autopsy there are found evidences of bronchitis 
of the tubes of all sizes, and minute zones of pneumonia about the smaller 
bronchi. The lungs are generally in a state of hyper-inflation, on account 
of which they do not collapse on opening the chest. There may be in 
addition extensive congestion or edema, the development of which has 
been the immediate cause of death. 

In cases which do not prove fatal there is usually by the third or 
fourth day great improvement in the general symptoms; the finer rales 
may disappear, and the coarse ones become more and more prominent. 
By the end of a week there may be complete recovery. Instead of this, 
there may be a continuance of the constitutional symptoms, and disap- 
pearance of the fine rales in front only, while behind there are gradually 
added to them the signs of consolidation in one of the lower lobes near 
the spine. From this time the case may progress as one of ordinary 
bronchopneumonia. 

The prognosis in this class of cases is very much better than in the 
congestive variety, recovery being probable unless the patients are very 
young or delicate infants. 

3. Bronchopneumonia of the Common Type. — When primary, 
this usually begins suddenly with symptoms not unlike those of lobar 
pneumonia. This is the mode of onset in about two-thirds of the cases. 
In only about ten per cent is the pneumonia preceded by bronchitis of the 



508 DISEASES OF THE RESPIRATORY SYSTEM 

large tubes. In these the symptoms of bronchitis may slowly or rapidly 
merge into those of pneumonia. When the onset is sudden it is marked 
by high fever, frequently by vomiting, rarely by convulsions. In addition 
there are rapid respiration, cough, prostration, and sometimes cyanosis. 
The symptoms are more distinctly pulmonary than is generally the case 
in lobar pneumonia. 

The temperature, as a rule, is high; rarely is it continuously so, but 
it is of a remittent type. The daily fluctuations often amount to four or 
five degrees. The fever usually continues from one to three weeks, and 
subsides gradually rather than by crisis, though crises are by no means 
rare. Although, as a rule, we expect a high temperature with acute 
pneumonia, this is not invariable. Primary cases may run their course, 
and even terminate fatally, although the temperature has not been 
above 101° F. We have records of several such cases. A low temperature 
is more often seen in young and delicate infants than in those who are 
older and more robust. 

The respirations are frequent and labored; there is real dyspnea. 
On inspiration, there are marked recessions of all the soft parts of the 
chest, and the alae nasi dilate actively. The usual rapidity of the respira- 
tions is from 60 to 80 per minute; very often, however, it rises to 100, 
and on several occasions we have seen it even 120. Eespiration generally 
seems more embarrassed than does the action of the heart, and respiratory 
failure is a more frequent cause of death than cardiac failure. The 
pulse is always rapid — from 150 to 200 a minute — and when so it is often 
irregular. The pulse rate is of much less importance than its character. 
Early the pulse is full and strong, but soon it becomes soft, compressible, 
and weak. 

The prostration is usually moderate for the first day or two, but 
steadily increases as the lung becomes more and more involved, and 
toward the close of the disease may be extreme. 

Cough is much more constant than in lobar pneumonia, and more 
distressing; sometimes it is almost incessant. It disturbs rest and sleep, 
and may cause vomiting if the paroxysm occurs soon after eating. There 
is no expectoration. Mucus is sometimes coughed up into the trachea, or 
even into the pharynx, to be swallowed again, or more frequently aspi- 
rated into the lung. If during a severe paroxysm the patient is turned 
upon his face or inverted, much of this mucus may be dislodged. A 
strong cough is a good symptom; suppression of the cough is a bad 
symptom, indicating a loss of the reflex sensibility of the bronchial 
mucous membrane and of the respiratory center. 

Pain in the chest is not common, and is rarely an annoying 
symptom. Cyanosis is present at some time in most of the severe cases. 
It may occur at the onset, or at any time during the course of the disease. 



ACUTE BRONCHOPNEUMONIA 



509 



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1 2 


3 


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5 


6 7 8 


9 


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11 


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100° 
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It is usually due to sudden congestion of a portion of the lung not 
previously involved. Even when slight, it is always a danger-signal of 
respiratory failure, and when present only in the finger tips or lips 
indicates that the patient must he carefully watched and energeti- 
cally treated. In the severe cases the whole body may be of a dull 
leaden hue. 

Nervous symptoms at the onset are not so frequent as in lobar pneu- 
monia, convulsions being rare; but late convulsions, particularly in the 
pneumonia which complicates pertussis, are frequent, and when present 
the disease is usually fatal. Delirium may occur at any time during the 
attack. In infants this shows it- 
self by excitement and inability 
to recognize the nurse or mother. 
Occasionally patients present 
marked cerebral symptoms 
throughout the disease closely 
simulating those of meningitis. 
As elsewhere stated, the nervous 
symptoms depend less upon the 
location of the disease than upon 
its extent, the intensity of the in- 
fection, and upon the susceptibil- 
ity of the patient, such symptoms 

being especially common in rachitic children and in those suffering from 
pertussis. 

Gastro-enteric symptoms are frequent in infancy, and are of much 
importance. Often there are from four to six stools a day, of a green 
color, containing mucus and undigested food. These symptoms depend 
upon the feeble digestion which is associated with the febrile process, 
and are often aggravated by improper feeding and overmedication. Vom- 
iting and diarrhea add much to the danger of the attack. In summer 
this complication is more frequent and is likely to be more severe. Dis- 
tention of the stomach or intestines from gas may be the cause of dis- 
tressing symptoms, owing to the added embarrassment of respiration 
produced by this upward pressure. In infants it may lead to attacks of 
cyanosis and even to convulsions. 

The blood in acute bronchopneumonia shows regularly the changes 
of a moderate secondary anemia, which in protracted cases becomes very 
marked. A leucocytosis is almost invariably present. In an average 
case this ranges from 20,000 to 40,000. It sometimes is excessively high 
without any apparent reason. We have several times seen it over 100,000. 
The increase is chiefly in the polymorphonuclear cells which usually 
form from sixty to eighty-five per cent of the total leucocytes. With 
18 



Fig. 52. — Temperatuee Curve in Typical 
Bronchopneumonia of the Milder 
Form. History. — Male, sixteen months 
old; delicate child; previous bronchitis; 
onset gradual; signs of consolidation at 
left base on fifth day, but fine rales over 
both lower lobes behind; resolution slow, 
rales persisting for a long time in both 
lungs. 



10 



DISEASES OE THE RESPIRAIORY SYSTEM 



the fall in temperature the leucocytosis in most cases rapidly disappears. 
A rapid diminution in the leucocytosis may indicate a marked loss of 
resistance in the patient; and may be seen with either a high or a low 
temperature. In the pneumonia which complicates pertussis, the in- 
crease in the white cells may be chiefly of the lymphocytes. 



107° 
106° 
105° 
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103° 
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101° 
100° 
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Fig. 53. — Temperature Curve of Bronchopneumonia with a Prolonged Course; 
Recover*. History. — Female, eighteen months old; in fair condition ; sudden onset. 
Early signs were localized, fine rales over left base; on fifth day signs of consolidation 
at left base, with rales on both sides behind. General symptoms of moderate severity. 
Signs of consolidation disappeared about a week after cessation of fever; rales per- 
sisted nearly two weeks longer. 

Positive blood cultures were obtained in 75 of 315 consecutive cases 
of bronchopneumonia studied at the Babies' Hospital. The pneumococ- 
cus was found in 47, the streptococcus in 15 cases. 

The urine in most cases is scanty, high-colored, and loaded with 
urates. A trace of albumin is often present when the temperature is 




Fig. 54. — Temperature Curve of Relapsing Bronchopneumonia; Recovery. 
History. — Male, nineteen months old; delicate. Consolidation on sixth day in loft 
lower lobe behind; two days later small area of consolidation in right lower lobe 
behind; many rales both sides; eighteenth day, signs of consolidation had disap- 
peared, but many rales persisted. Accession of fever on nineteenth and twentieth 
days, accompanied by extension of disease as shown by new rales, but no evidences of 
consolidation during second attack. Slow resolution and convalescence. 



very high; but casts, renal epithelium, aud a large amount of albumin 
are rare. 

The temperature chart shown in Fig. 52 is a good example of a very 
frequent course of primary pneumonia of moderate severity terminating 
in recovery. In cases of this type the constitutional symptoms arc not 
grave, and follow very closely the temperature curve. 



ACUTE BRONCHOPNEUMONIA 



511 





1 


2 3 


1 


5 





7 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 




















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1 




1 


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The next chart (Fig. 53) illustrates a more severe but not uncom- 
mon course of the disease in which the fever is prolonged. The usual 
duration of cases of this type is between three and four weeks. The 
irregular fluctuations of the temperature, rarely touching the normal line, 
are exceedingly characteristic of bronchopneumonia. 

The chart shown in Fig. 54 is that of 
relapsing pneumonia. The first attack was 
fairly typical, with about the usual dura- 
tion. Resolution had begun, and was ap- 
parently progressing favorably, when there 
was a return of the fever, accompanied by 
new signs in the chest, the second attack 
being shorter and milder than the first. 
Very often the temperature falls to normal 
without any signs of resolution, and after 
an interval varying from two to three days 
to a week there is a recurrence of the fever 
and other constitutional symptoms, the 
second attack frequently proving fatal. 

A frequent course in fatal cases is shown 
in Fig. 55. The duration of the diseaee, 
instead of being five days as in this case, is 
often only three or four. The temperature 
at first fluctuates widely, then rises grad- 
ually until death. 

Duration of the Fever. — The following 
figures give the duration of the fever in 231 cases. The majority were 
primary ; none were secondary to diphtheria, and only a few complicated 
measles. Of the 169 cases that were fatal — 

There died during the first six days 25 . per cent. 

" between the seventh and twenty-first days 55 . 5 " " 
" twenty-first and sixtieth days 19.5 " " 

100.0 " " 
Of 78 cases which recovered, the duration of the fever was — 



Fig. 55. — Temperature Curve 
of Bronchopneumonia; Fa- 
tal. History. — Male, six 
months old; markedly ra- 
chitic; sudden onset. Signs 
first day were fine moist rales 
throughout the chest, marked 
prostration, and cyanosis; on 
third day, a small area of con- 
solidation in upper lobe of left 
lung behind; increasing pros- 
tration, cyanosis, and death. 
Autopsy. — No pleurisy; con- 
solidation at left apex behind, 
and posterior two-thirds of left 
lower lobe; consolidation of 
right apex posteriorly, lower 
lobe intensely congested. 



Less than seven days 11.5 per cent. 

From seven to twenty-one days GG.6 " " 

" twenty-one to ninety days 21.9 " " 

It u 

100.0 " " 

Physical Signs. — In considering the signs of bronchopneumonia, it is 
better to connect them with the different conditions in the lung than to 
group them in stages, as in lobar pneumonia. 



512 DISEASES OF THE RESPIRATORY SYSTEM 

(a) Without Consolidation. — It can not too often be repeated that 
bronchopneumonia may exist without signs of consolidation at any 
period during the course of the disease. When the attack is primary, the 
earliest signs are due to congestion of the lung associated with bronchitis 
of the fine tubes, which is usually localized, but which may be general. 
If the disease has followed bronchitis of the large tubes, its signs are 
added. Congestion of the lung gives feeble breathing over the affected 
area and occasionally slight dulness or diminished resonance. With this 
are found coarse sonorous, and finer sibilant rales, due to congestion and 
swelling of the mucous membrane of the larger and smaller bronchi 
respectively. These signs are soon replaced by very fine moist rales, 
which are usually localized in one of the loAver lobes behind (Fig. 56). 
These localized fine rales are the first distinctive sign of bronchopneu- 
monia. Soon a change in the respiratory murmur is heard in the affected 
area, which becomes feebler in intensity and higher in pitch. Elsewhere 
in the chest there may be coarse rales, due to bronchitis of the large tubes. 
In such cases the areas of pneumonia are so small and so scattered as to 
give in themselves no additional signs, and the case may go on to re- 
covery without presenting anything more distinctive than the signs men- 
tioned. 

(b) With Areas of Partial Consolidation. — In the lung at this 
time there are small areas of consolidation, generally superficial and 
separated by healthy or congested lobules. Percussion in these cases 
may give negative results or there is slight dulness. The vocal fremitus 
is not usually altered. The fine moist rales may be heard over quite a 
large area, but at some point, usually near the spine, over one of the 
lower lobes, they are sharper, louder, higher pitched, and more metallic, 
and seem close under the ear (Fig. 57). Eespiration is feebler here 
than elsewhere, and bronchovesicular in quality, approaching bronchial 
breathing more and more as the consolidation increases. The resonance 
of the voice and cry is exaggerated. 

(c) With Areas of Consolidation More or Less Complete. — On per-- 
cussion there is dulness, but surprisingly little in comparison with the 
other signs of consolidation present. It is due to the fact that the 
consolidated portion, though extensive, does not involve the lung to 
any great depth, and also that there are in the consolidated area many 
alveoli which still contain air (Plate VIII). On palpation there is 
usually a slight increase in the vocal fremitus. On auscultation, there 
are still present the evidences of bronchitis, usually only behind, but 
sometimes over the entire chest. Coarse and fine rales are inter- 
mingled. Over the consolidated parts are heard bronchial breath- 
ing and bronchial voice. At the center of these areas the bronchial 




Fig. 56. — First Stage. Coarse rales over both 
lungs; localized fine (subcrepitant) rales at 
the left base. No change in breath sounds. 



Fig. 57. — Second Stage. Coarse and fine rales 
over both lungs behind ; at left base an area 
of partial consolidation, with bronchovesic- 
ular breathing, exaggerated voice, and very 
sharp rales. 




Fig. 58. — Third Stage. A larger area of partial Fig. 59. — Fourth Stage. Extensive disease of 



consolidation, and in the center a small area of 
complete consolidation, with bronchial breath- 
ing and voice and slight dulness. Signs over 
the right lung similar to what were previously 
present over the left. 



both sides; large area of complete consoli- 
dation on the left, with dulness, bronchial 
breathing and voice, and no rales; surround- 
ing this, bronchovesicular breathing, with 
many rales. Signs in the right lung similar 
to those previously present, over the left. 



Note. — The large circles indicate coarse rales; the small ones finer rales; the red areas indicate 
consolidation partial or complete. The disease may stop at any one of these stages and resolution 
take place. 



513 



*,' 



514 DISEASES OF THE RESPIRATORY SYSTEM 

breathing is pure and rales are usually absent, but at the margin 
rales are present and the breathing approaches the broncho-vesicular 
type (Fig. 58). The signs of consolidation are rarely sharply circum- 
scribed as they are in lobar pneumonia, but shade off gradually. The 
consolidated area is at first small, usually in one of the lower lobes near 
the spine, but may gradually extend until nearly the whole of one or 
even both lungs behind are more or less completely solidified (Fig. 59). 
The signs are found as far forward as the axillary line, but usually stop 
there. Friction sounds may be heard over the consolidated areas, but 
very rarely except where signs of complete consolidation are present. It 
is often impossible to obtain any idea of the condition of an infant's lung 
during quiet, superficial respiration. Sometimes over a part which is 
completely consolidated there is heard only very feeble breathing, or 
the lung may be almost silent. If, however, the child is made to cry 
or to take a deep inspiration, both the bronchial breathing and rales are 
distinctly brought out. The intensity of the consolidation increases as 
the disease advances, and the signs become more and more like those of 
lobar pneumonia. During resolution there is first a disappearance of 
the signs of consolidation, which may be quite rapid, but friction 
sounds and rales of all kinds often persist for three or four weeks 
longer. 

The following statistics are of some interest, as showing the frequency 
with which signs of consolidation were found, and the day when they 
were discovered. Their value is increased by the fact that the children 
were under observation in an institution at the time they were taken 
sick, and that in all the fatal cases — thirty-six in number — in which signs 
of consolidation were absent, the diagnosis of pneumonia was confirmed 
by autopsy: 

Consolidation noted on or before the fourth day 47 cases 

" " from the fifth to the seventh day 36 " 

■ " " the eighth to the twelfth day.... 12 " 

" " after the twelfth day 9 " 

No signs of consolidation 62 " 



166 



a 



In general, it must be borne in mind that in many cases signs of 
consolidation are never present, as the areas of pneumonia are small and 
widely scattered; that where there is consolidation it is usually incom- 
plete, because there are small areas of healthy lung tissue between the 
hepatized portions; that the signs of consolidation usually shade off 
gradually; and that both sides are almost invariably involved, although 
one side usually to a greater degree than the other. 



ACUTE BRONCHOPNEUMONIA 



515 



4. The Protracted Form — Persistent Bronchopneumonia. — 
This is seen in primary cases, especially among delicate children, and 
in the pneumonia complicating pertussis, influenza and measles, and is 
the form which often follows diphtheria. The onset and course of the 
disease for the first two or three weeks do not differ from an ordinary 
attack of moderate severity, but at the end of this period there is seen 
no tendency in the process to subside. The fever continues, although it 
may not be high, but by physical examination it is found that the areas of 
consolidation are gradually increasing day by day, until sometimes the 
greater part of both lungs behind are involved. The air vesicles become 
so distended with cells that the signs of consolidation are more complete 
than in ordinary bronchopneumonia. The physical signs present are 



107 

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Fig. 60. — Temperature Curve of Persistent Bronchopneumonia. Terminating 
Fatally. History. — Male, two and a half years old; healthy; sudden onset; for two 
weeks the only signs were very fine moist rales throughout both lungs, front and back. 
The rales in front in great part gradually cleared up ; those behind persisted, but it was 
not until the thirty-fourth day that positive sign# of consolidation were discovered in 
the left lower lobe behind; these signs gradually extended, and, before death, were 
present over nearly the whole left lung behind and over the right lower lobe. There 
were also friction sounds over both lungs. Autopsy. — Old and recent pleurisy with 
general adhesions; left lower lobe completely solid, patches of consolidation in left 
upper lobe. Right lower lobe about one-half consolidated, with patches elsewhere. 
Bronchial glands large, but not cheesy. No evidence of tuberculosis upon either 
gross or microscopical examination (see Fig. 51). 



marked dulness, sometimes almost flatness; there is bronchial breathing 
which is exaggerated in intensity until it resembles cavernous breathing, 
and it may be impossible to distinguish between them. However, the 
fact that it is heard over so large an area, that it shades off gradually, 
and that it is accompanied by friction sounds, usually make a distinction 
possible. 

The temperature in these protracted cases for the first two or three 
weeks is from 100° to 105° F. ; but after this time it is generally lower 
—from 100° to 102° or 103° F. The course is not at all regular, but 
marked by frequent exacerbations and remissions. The general symp- 
toms are those of progressive asthenia. There is continued wasting, 
anemia, and steadily increasing prostration. The appetite is lost, often 
there is an aversion to food, and vomiting is easily excited if food or 
stimulants are forced. The stools show that even what food is taken is 
very imperfectly digested and assimilated. The skin becomes dry and 
loses its elasticity; bed-sores may form; fine punctate hemorrhages are 



516 



DISEASES OF THE RESPIRATORY SYSTEM 



107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
90° 


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seen over the abdomen, sometimes over the chest and- extremities. This 
condition is always a very bad symptom, and recovery from pneumonia 
is very seldom seen when it is present. • 

Death takes place from slow asthenia, usually after five or six weeks, 
but the attack may be prolonged for eight or ten weeks. The general 
symptoms, the temperature, and the wasting strongly suggest tubercu- 
losis, and such is the diagnosis often made. 

Although the majority of the cases in which the fever lasts over four 
weeks run the fatal course just described, such apparently hopeless cases 
occasionally recover. The temperature gradually falls lower and lower, 

until it remains at the normal 
jDoint. For some time after this, 
often two or three weeks, little 
change can be seen either in the 
general symptoms or in the 
physical signs. Gradually the 
appetite returns, the child is 
brighter and begins to take an 
interest in his surroundings, the 
cough abates, and little by little 
the signs in the lungs clear up, 
and the child may recover com- 
pletely. Convalescence, how- 
ever, is always slow, and may 
be interrupted by relapses, it 
being many months before 
health is fully restored. Although the signs of consolidation disappear in 
a few weeks, rales are apt to persist for a much longer time. It is prob- 
able in such cases, even though all signs of disease disappear from the 
chest, that the lung does not become normal. Eelapses and second at- 
tacks are always possible and indeed frequently occur. The area in- 
volved in the relapse always includes that part of the lung in which reso- 
lution was delayed. The general health may be so undermined that 
the child never regains his former vigor; yet in a surprising number 
of these cases recovery seems to be complete. Protracted cases of a mild 
type are sometimes seen, and, although the tmperature persists for a 
number of weeks, it is never high. The course of the disease suggests 
tuberculosis. 

5. Secondary Pneumonia. — (a) Complicating Pertussis. — It is not 
often that pneumonia develops during the first two weeks of this dis- 
ease. The most frequent time is from the third to the fifth week, when 
the patient has become exhausted from the previous severity of the per- 
tussis. In two-thirds of our cases the development of the pneumonia 



Fig. 61. — Temperature Curve of Fatal 
Bronchopneumonia, Complicating Per- 
tussis. History. — Male, six months old; 
delicate; pertussis for three weeks. Early 
signs of bronchitis of large tubes only; on 
the eleventh day signs of consolidation in 
right upper lobe. Increasing prostration, 
cyanosis, and death. Autopsy. — Large 
areas of consolidation in right middle and 
upper lobes, small scattered spots through- 
out left lung. 



ACUTE BRCTCCHOPXEOIOXIA 517 

was gradual, following bronchitis of the larger tubes. The temperature 
chart shown in Fig. 61 well illustrates this course. 

When the onset is sudden, the symptoms do not differ essentially from 
those of primary pneumonia. The temperature of pertussis-pneumonia 
is usually not high, in a very large number of cases not rising above 
103.5° F., and ranging most of the time from 101° to 103° F. These 
cases are very apt to be prolonged, the fever often lasting for three or 
four, and sometimes even for six weeks. The physical signs of consoli- 
dation may persist for a long time after the temperature has become 
normal, and yet the child may recover entirely. "We have seen one case 
in which recovery apparently complete occurred after the signs of con- 
solidation had persisted for six months, and another in which they had 
persisted for over eight months. Very often the signs continue during 
the entire attack of pertussis. Cerebral symptoms are common, espe- 
cially toward the close of the disease. Of fifty-four fatal cases, twenty- 
five had convulsions, and in twenty-two this was the mode of death. 
Only one case which developed convulsions recovered. 

(b) Complicating Measles. — In a small number of cases the pneu- 
monia begins simultaneously with the invasion of measles, but generally 
not until the eruption appears. Instead of gradually falling to normal 
with the fading of the eruption, the temperature continues high. Any 
of the clinical types of primary pneumonia may occur in measles, the 
acute congestive variety, which is fatal in two or three days, being 
especially common. In its course and duration the pneumonia of 
measles resembles the severe form of primary pneumonia. The broncho- 
pneumonia of scarlet fever differs in no Avay from that of measles. 

(c) Com p/icating Diphtheria. — In many cases this does not give a 
distinct clinical picture of its own, its symptoms being mingled with 
those of diphtheritic bronchitis, with which it is frequently associated. 
In others the forms resemble those seen in measles. The majority of 
cases occur as a complication of diphtheria of the larynx, although it is 
not infrequent in the septic cases in which only the upper air passages are 
involved. Pneumonia after laryngitis may develop within two days 
from the beginning of laryngeal symptoms, and run a rapid course; or 
it may come as late as the second or third week. In a child wearing an 
intubation tube, the diagnosis of pneumonia presents difficulties, owing to 
the alteration in the respiratory sounds and the existence of the loud 
tracheal rales which obscure the usual auscultatory signs. Although 
pneumonia may be apparent by symptoms, its situation may be difficult 
to determine. The most important signs for diagnosis are the diminished 
respiratory murmur, localized rales, and dulness on percussion. 

('/) Complicating Influenza. — Without doubt many cases usually re- 
garded as primary arc really secondary to influenza, particularly when 



518 



DISEASES OF THE RESPIRATORY SYSTEM 



that disease is prevalent. While the pneumonia of influenza may differ 
in no essential points from the primary form, there are types which are 
quite characteristic. In one variety the cases are of short duration, fre- 
quently lasting but three or four clays, but with high and often widely 
fluctuating temperature, the general symptoms being of only moderate 
severity. A second type is a prolonged pneumonia with exacerbations 
and remissions, which may last for two or three months with quite 
extraordinary fluctuations of temperature (Fig. 62). A third form is 
the recurrent type of pneumonia, of which a child may have several 



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28 


29 


30 


31 


32 


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34 


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103° 
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Fig. 62. — Bronchopneumonia Complicating Influenza; Death. History. — Delicate 
infant, 7 months old, bronchitis and otitis four weeks before. Acute onset, early 
signs of consolidation in right lung; double paracentesis for otitis on 13th day; 
small area of consolidation in left lung on 16th day. Sputum cultures repeatedly 
showed B. influenzae. Signs in lungs not much changed; death from exhaustion. 
Autopsy. — Usual lesions of bronchopneumonia of moderate extent in both lungs. No 
other lesions of importance. Cultures from lungs showed the B. influenzae but no 
pneumococci. 



distinct attacks in a single season, although in the interval neither 
signs nor symptoms entirely disappear. In a certain number of these 
cases a chronic form of pneumonia ultimately develops. 

(e) Complicating Ileocolitis. — This is usually a somewhat subacute 
form of pneumonia which is scarcely recognizable except by the physical 
signs. It is seen in the protracted cases of ileocolitis and occurs late 
in its course. Very often pneumonia is not suspected during life, the 
constitutional symptoms being sufficiently explained by the intestinal 
lesions, although the autopsy discloses the fact that death was due in 
part to pneumonia. 

Complications. — Most of those relating to the lungs have been de- 
scribed with the lesions. Pleurisy will be separately considered. Pul- 
monary emphysema is always present to a greater or less degree, but 
can not be made out by physical signs. In very rare instances subcuta- 
neous emphysema has been seen. Abscess and gangrene can seldom be 
recognized by physical signs. Pneumothorax occurs even in infancy, but 
is very infrequent except as a result of puncture of the chest. Otitis is 



ACUTE BRONCHOPNEUMONIA 519 

exceedingly common, and one should be constantly on the lookout for 
it. It is recognized only by examination of the ear with a speculum. 

Meningitis may complicate acute bronchopneumonia. It has oc- 
curred in about two per cent of our cases. It is in all respects similar to 
that occurring with lobar pneumonia. Meningeal hemorrhage we have 
seen only once, and it was the cause of death in a patient eleven months 
old, who a few days before was seized with convulsions, followed by a 
gradually increasing stupor, which, continued until death. The hemor- 
rhage covered the entire convexity of the brain. Endocarditis is ex- 
tremely rare ; it was not observed in any of our cases. Acute pericarditis 
is also rare unless there is an extensive pleurisy. When it occurs it is 
usually with pneumonia of the left side. Complications referable to 
the digestive tract are quite common. Herpetic stomatitis is frequent, 
and occasionally the ulcerative variety is seen. Thrush often occurs in 
the protracted cases among very young infants. Gastro-enteritis is not 
very common, considering the frequency of vomiting and diarrhea, these 
depending usually upon functional derangement. Nephritis is rare ; it is 
usually of the acute exudative variety, and very seldom severe enough 
to affect the prognosis. 

Old lesions of tuberculosis- — cheesy nodules in the lungs and some- 
times in the pleura — are not infrequently met with in patients dying of 
acute pneumonia of a non-tuberculous character. 

Diagnosis,. — An acute onset with continuous high fever, rapid res- 
piration, and cough, should always lead one to suspect pneumonia. When 
to these symptoms are added prostration and a leucocytosis, the diag- 
nosis of pneumonia is almost certain. Cases of the acute congestive type 
are the ones most frequently unrecognized, and in many of these cases 
a positive diagnosis is impossible during life. Many atypical cases of 
pneumonia are seen, particularly in young infants. An unusual tem- 
perature course is perhaps the symptom most likely to lead to a mistake. 
While this, as a rule, is high and remittent, sometimes it is not so, and 
it may be but little above normal. Kapid respiration is almost always 
] »rcsent, but cough may be very slight, especially in infants. In very 
young infants, the diagnosis often rests upon the prostration, cyanosis, 
and rapid respiration, the other acute inflammatory symptoms being 
absent. Only the physical signs of the disease can positively settle the 
question of diagnosis. 

When pneumonia follows bronchitis of the large tubes, whether the 
bronchitis is primary or complicates one of the infectious diseases, the 
extension of the disease to the lungs is usually marked by three symp- 
toms — a steadily rising temperature, more frequent respirations, and in- 
creasing prostration. It may be twelve or twenty-four hours before the 
change is indicated by the physical signs. 



520 



DISEASES OF THE RESPIRATORY SYSTEM 



At the outset, pneumonia can not be positively diagnosticated from 
severe bronchitis. Such a bronchitis often begins with severe pulmonary 
symptoms and a temperature of 103° or 104° F. ; but this high tempera- 
ture is of short duration, usually falling after twenty-four or forty-eight 
hours to 100° or 101° F. The prostration is much less and all the 
symptoms, possibly excepting the cough, less severe. The only physical 
signs are coarse rales, which are heard throughout the chest. 

The same rules apply to bronchitis of the smaller tubes. The rales are 
heard both in front and behind, and usually over both sides. If with such 
rales the temperature continues to rise for three or four days in succession 

above 103° F., it may 
be assumed that pneu- 
monia is present, pro- 
vided there is no other 
disease which might ex- 
plain the temperature. 
If the signs of bronchi- 
tis are limited to a sin- 
gle lung, or to one lung 
posteriorly, the exist- 
ence of bronchopneu- 
monia may be regarded 
as certain. Localized 
bronchitis, then, is al- 
ways to be interpreted 
as bronchopneumonia, 
provided tuberculosis 
can be excluded. 

The differential di- 
agnosis of bronchopneumonia from lobar pneumonia will be considered 
in connection with the latter disease. On account of the remittent tem- 
perature, bronchopneumonia may be confounded with malarial fever; or 
malaria may be suspected as a complication. An examination of the 
blood will remove the doubt. 

Both the acute and the persistent forms of simple bronchopneumonia 
may be confounded with the tuberculous form: the points of distinction 
are considered in the chapter on Tuberculosis. 

The X-ray is of value in detecting the presence of consolidation 
before this can be made out by physical signs. (See Fig. 63.) Small 
scattered areas of bronchopneumonia cannot be differentiated from tu- 
berculosis. Large areas of consolidation do not differ in their appear- 
ance from those of lobar pneumonia. 

Prognosis. — Bronchopneumonia is always a serious disease, and in an 




Fig. 63. — Bronchopneumonia. Infant 8 months old; 
areas of consolidation in both lungs, especially marked 
at the left apex and the root of the right lung. The 
only physical signs were scattered rales. 



ACUTE BRONCHOPNEUMONIA 



521 



infant dangerous to life. The prognosis depends upon the age, sur- 
roundings, and previous condition of the patient, upon the nature of the 
infection, whether the disease is primary or secondary, and, if the latter, 
upon the character of the primary disease. In private practice the mor- 
tality from bronchopneumonia is from ten to . twenty per cent, depend- 
ing upon the conditions mentioned. One whose knowledge of broncho- 
pneumonia is derived from observations in private practice can, however, 
form but little idea of the frequency and severity of this disease in hos- 
pitals and asylums for infants and young children, particularly when it 
occurs with epidemics of measles, diphtheria, or pertussis. The statis- 
tics in the following table are taken from the records of two institutions, 
and fairly represent the results seen in such places in children under 
three years : 



Forms of Pneumonia. 



Cases. 



Deaths. 



Percentage 
Mortality. 



Primary bronchopneumonia 

Following bronchitis of the large tubes 
Secondary to measles 

" " pertussis 

" " scarlet fever 

" " diphtheria 

u " ileocolitis 

" " epidemic influenza 

" varicella 

" " erysipelas 

Totals 



194 

29 

89 

66 

7 

47 

19 

6 

2 

2 



461 



96 

19 

56 

54 

7 

47 

18 

1 

2 

2 



302 



49.4 

65.5 

62.9 

81.8 

100.0 

100.0 

94.7 

16.6 

100.0 

100.0 



65.5 



The mortality varies with the age of the patient, being highest dur- 
ing the first year, and diminishing steadily thereafter, as shown by the 
following table giving the result in 346 cases : 



Age. 


Cases. 


Percentage 
Mortality. 


During the first vear 


202 

102 

33 

6 

3 


66 


" " second vear 


55 


" " third u 


33 


" fourth " 


16 


" fifth " 









In this table are included no cases secondary to measles, scarlet 
fever, or diphtheria. 

Probably the best of all guides to the nature and severity of the in- 
fection is the temperature. An excessively high temperature usually 
indicates a severe type of infection. Some idea of this may bo gained 



522 



DISEASES OF THE RESPIRATORY SYSTEM 



from these figures, giving the highest temperature and the mortality in 
two hundred and thirty-one cases, not including cases with measles or 
diphtheria : 



Highest Temperature. 


Cases. 


Deaths. 


Percentage 
Mortality. 


106° F. or over . 


55 
94 
53 
22 

7 


47 
56 
26 
13 
5 


85 5 


105° or 105 5° F 


60 


104° or 104.5° F 


49 


102° to 103.5° F 

99.5° to 101.5° F 


60.0 
71.0 







The high mortality of the cases with unusually low temperature is 
due to the fact that they nearly aways were seen in infants with very 
feeble vitality. The outlook in cases with a steadily high temperature — 
between 102.5° and 104° F. — is usually more favorable than in those 
with wide fluctuations, such as 100° to 105.5° F. As a rule, the danger 
from the disease increases steadily w r ith every degree of temperature 
above 104.5° F. 

An important factor in the prognosis is the previous condition of the 
patient. The association with rickets is unfavorable, both on account 
of the feeble muscular power of these children and their thoracic de- 
formities. Marked and persistent tympanites is always an unfavorable 
symptom. As a rule, second attacks are more serious than the primary 
ones, especially if the interval between them is short. 

In making the prognosis in any given case, the symptoms to be con- 
sidered are the height and course of the temperature, the presence or 
absence of nervous symptoms, the condition of the organs of digestion, 
the presence of cyanosis and the extent of the disease as shown by the 
physical signs. We have not found the examination of the blood to aid 
greatly in prognosis. The leucocyte count varies widely and often with- 
out apparent reason. Blood cultures, however, are of some assistance. 
In our hospital cases which gave positive blood cultures, the mortality 
was 70 per cent, while in those which gave negative cultures it was 
44 per cent. 

Convulsions occurring early in the disease do not affect the prognosis: 
but of thirty-seven cases in which convulsions occurred at a late period 
all but one proved fatal. 

So long as the nutrition of the patient can be well maintained, no 
protracted case is hopeless, no matter how extensive the local disease 
may be; but the existence of vomiting, diarrhea, or persistent tym- 
panites makes the issue doubtful, even though the other symptoms are 
favorable. 



ACUTE BRONCHOPNEUMONIA 523 

Treatment. — The most important part of prophylaxis is to give care- 
ful and early attention to every attack of bronchitis in an infant, for 
every such attack should be regarded as a possible precursor of pneu- 
monia. It is striking that one sees bronchopneumonia so seldom in 
private practice among the better classes, even though bronchitis is very 
frequent; while among hospital and dispensary patients, where bron- 
chitis is very often neglected, bronchopneumonia is constantly seen. 
Cases of measles and diphtheria which are complicated by pneumonia 
should, if possible, be carefully isolated from others, and wards in which 
they are treated should be thoroughly disinfected before they are used 
for simple cases. 

The hygienic treatment of bronchopneumonia is important, and 
usually it receives too little attention. It is much the same as that of 
cases of acute bronchitis already discussed. What was said in that con- 
nection regarding the necessity for fresh air and the caution as to very 
cold air, may be here repeated. The cold-air treatment is not admis- 
sible in very young or delicate infants, nor in cases of disseminated 
pneumonia (capillary bronchitis). The best results from this treat- 
ment are seen in the cases with extensive consolidation and with the 
minimum amount of bronchitis, and it is to be highly recommended in 
the pneumonia of the severe acute infections — diphtheria, measles, and 
scarlet fever. The dress and protection of the patient with the cold-air 
treatment are discussed under Lobar Pneumonia. 

Older children with pneumonia should be kept in bed. Infants for 
a considerable part of the time may be held in the nurse's arms. A 
frequent change of position in all cases is essential; no child should be 
allowed to lie for hours directly on the back. The general rules pre- 
viously laid down for feeding all sick children should be followed here. 
As a rule, medicine should not be administered in the food. 

The same local treatment may be employed as in cases of bronchitis. 
Counter-irritation, best by means of the mustard paste, may be em- 
ployed from three to six times daily. It is of the greatest value in the 
early stage of acute pulmonary congestion, and during attacks of cardiac 
or respiratory failure. Poultices should not be used. 

Alcohol may be needed in pneumonia secondary to diphtheria, 
measles, or scarlet fever, also in many primary cases. Its use has been 
greatly abused in this disease. Although there is little doubt that it is 
at times of much benefit, there is considerable doubt as to its mode of 
action. The dose is to be regulated by the condition of the patient. Not 
over one-half ounce daily should be given to an infant of one year. 

Of the circulatory stimulants, caffein, camphor, and digitalis may be 
used, and are recommended in the order named. 

For a child of one year the following doses are suitable: Caffein, gr. 



524 DISEASES OF THE RESPIRATORY SYSTEM 

I to gr. | every three hours; camphor is especially valuable for quick 
effect; TTi iij to v of a ten per cent solution in oil may be given hypoder- 
mically; digitalis, the fluid extract is generally to be preferred as more 
reliable than the tincture, Tit i may be given every four hours. For 
immediate effect in sudden heart or respiratory failure, nothing com- 
pares with epinephrin given intramuscularly — doses TTj, ij to TU v of a 
1-1,000 solution; atropin, also used hypodermically, is sometimes useful 
— dose, gr. T -J- T . Oxygen may be given continuously, but always mixed 
with atmospheric air. It sometimes seems to benefit greatly cases 
with marked cyanosis; often it does no good. Gentle friction of the 
chest wall, without disturbing the patient, is sometimes useful in stimu- 
lating the respiratory muscles, especially in protracted cases. 

It should be remembered that the normal range of temperature in 
bronchopneumonia is from 101° to 104.5° F. This temperature is not 
in itself exhausting, and the chances of recovery are not improved 
by reducing it so long as it remains within these limits. Too much 
Can -not be said in condemnation of the practice of giving the coal-tar 
products in full doses for the reduction of temperature. In small doses 
they are often useful to allay nervous irritability, restlessness, and 
promote sleep. 

Antipyretic measures are indicated in cases of hyperpyrexia, which 
we may define as 105° F. or over, especially when extreme nervous symp- 
toms exist. In these circumstances, the most certain, the most 
within our control, and hence the safest antipyretic, is cold. It may be 
used by the evaporation bath, the cold pack, sponging, cold com- 
presses, or an ice-bag applied to the chest. (See chapter on General 
Therapeutics.) 

Not all children bear cold well, and in its use and frequency of repe- 
tition one must be guided by its effect upon the child's general condition 
as well as upon the temperature. When with hyperpyrexia we have 
general cyanosis, cold surface, feeble pulse, shallow respiration, and 
stupor, cold is contraindicated and a hot mustard bath should be used. 

Inhalations are of more value in relieving cough and in promoting 
bronchial secretion than any other means we possess. The same sub- 
stances are to be used, and in the same way as mentioned in the article 
on Bronchitis. 

The nervous symptoms, — restlessness, loss of sleep, etc., — are often 
best controlled by cold or tepid sponging; in other cases by small doses 
of phenacetin — i.e., one grain every three hours to a child of six months. 
Opium is to be avoided unless there is severe pain, which is very rare; 
or when the incessant cough is not relieved by inhalations. Codein may 
be given in doses of gr. -^ every three or four hours to a child of one. 
year, or morphin in half this dose. 



ACUTE BRONCHOPNEUMONIA 525 

Sudden attacks of general collapse with cyanosis are frequent in 
severe cases of bronchopneumonia. They may come on at any period in 
the disease. When occurring in the early stage, if promptly and ener- 
getically treated, recovery may take place, but when they come on in the 
late stages they are usually fatal. They may be due to acute congestion 
or edema of the lung not previously involved, or to circulatory failure. 
The most efficient treatment is the use of dry cups or the hot mustard 
bath, the administration of epinephrin and caff em or camphor hypoder- 
mically, and to give oxygen continuously. 

When the fever continues for five or six weeks, with no disposition 
on the part of the disease to subside, one should continue the sustain- 
ing treatment adopted in the earlier part of the disease — careful feed- 
ing and judicious stimulation, but most of all should these patients be 
given the benefit of the fresh-air treatment. Some apparently hopeless 
cases recover; but, unfortunately, in the majority the continuance of the 
pneumonic process is in itself evidence of the weakened vitality of the 
patient, and, though he may live a long time, usually such attacks prove 
fatal. 

When the fever has disappeared, and there is only a persistence of 
the physical signs and the general cachexia, the cases are more hopeful. 
Here, a change of air is more important than all other means of treat- 
ment. If in the winter or spring the child can be removed to a warm, 
dry climate where he can be kept in the open air, or, in the summer, 
he can be taken to the mountains, immediate improvement is often seen, 
followed by rapid recovery. With the change of air a general tonic plan 
of treatment should be followed, cod-liver oil, arsenic, and iron being 
used, according to the indications in each particular case. 

One should never declare one of these cases of protracted pneumonia 
to be hopeless, nor should he be too ready to assume that tuberculosis 
is present because the child is wasted and anemic, and the physical signs 
have persisted. 

Xo specific treatment of pneumonia has yet been proposed which can 
be recommended for general use. 



526 



DISEASES OF THE RESPIRATORY SYSTEM 



CHAPTER V 

DISEASES OF THE LUNGS.— (Continued) 



LOBAR PNEUMONIA 

(Fibrinous Pneumonia; Croupous Pneumonia) 

Etiology. — Age. — Lobar pneumonia ma}- occur at any age. We have 
seen it in an infant of three months; but it is not until after the first 
year that it begins to be frequent, iifter the third year most of the 
cases of primary pneumonia are of this variety. 

Of 500 cases the ages were as follows : 



Age. 


Cases. 


Per cent. 


During the first year 


76 
309 
104 

11 


15 


From the second to the sixth year 


62 


" " seventh to the eleventh year 


21 


" " twelfth to the fourteenth year 


2 






Totals 


500 


100 







Season. — In 136 cases the seasonal occurrence was as follows: 



Season. 


Cases. 


Per cent. 


In the three winter months 


48 

62 

6 

20 


35 


" " " spring " 


46 


" " " summer * 


4 


" * " autumn " 


15 






Totals 


136 


100 







Lobar pneumonia, in children therefore, as in adults, occurs most 
frequently during the spring months. March and April show the 
largest number of cases. 

Previous Condition. — In our hospital cases, eighty-two per cent of 
the children were previously in good condition, and only eighteen per 
cent were delicate, rachitic, or syphilitic. This observation has been 
borne out by our experience in private practice, viz., that as a rule lobar 
pneumonia affects children who were previously healthy. Or to state the 
matter differently, if a strong child contracts pneumonia it is nearly 
always of the lobar variety. 



LOBAR PNEUMONIA 



527 



Previous Disease. — Previous attacks of pneumonia are observed in 
but a small proportion of cases. It was noted only five times in 160 cases. 
In the vast majority of cases lobar pneumonia is a primary disease, al- 
though it occasionally occurs as a complication of pertussis, measles, 
typhoid or scarlet fever, and even diphtheria — chiefly, however, in chil- 
dren over three years old. 

Epidemics of lobar pneumonia we have never witnessed, although on 
several occasions we have seen two children in a family attacked either 
simultaneously or in rapid succession. Exhaustion, fatigue, and ex- 
posure are to be ranked as associated exciting causes. 

In addition to other causes, there is required for the production of 
the disease the presence and growth of the pneumococcus. Associated 
with it are often found the staphylococcus aureus and occasionally the 
bacillus of influenza. The bacillus of Friedlander is very seldom the 
exciting cause of pneumonia in children. It was found but once in blood 
cultures of 87 cases in the Babies' Hospital. 

Lesions. — The Seat of the Disease. — In 950 cases in children under 
fourteen years, this was as follows : 



Seat of Disease. 


Personal 
Cases. 


Collected 
Cases. 


Totals. 


Right lung, upper lobe only 


39 

8 

26 

13 


137 

4 

142 

64 


176 


" " middle " " 


12 


" " lower " " 


168 


" " more than one lobe 


77 






Totals, right lung 


86 


347 


433 






Left lung, upper lobe only 


25 

49 
9 


68 

214 

29 


93 


" " lower " " 


263 


" " more than one lobe 


38 






Totals, left lung 


83 


311 


394 






Both lungs, upper lobes 

lower " 


"3 
9 


13 

38 
60 


13 
41 


a elsewhere 


69 






Totals, both lungs 


12 


111 


123 











The right lung was thus affected in 45.5 per cent; the left lung in 
41.5 per cent; both lungs in 13 per cent. In the order of frequency, the 
disease involves, first, the left base; second, the right apex; third, the 
right base; fourth, the left apex. The disease affects, as a rule, a single 
lobe, and often only a circumscribed portion of a lobe. 

The anatomical changes resemble those seen in the adult lung. There 
is an exudation into the alveoli and smaller bronchi of fibrin, serum, 
leucocytes, and red blood-cells (Fig. 47). There is usually in addition 



528 DISEASES OF THE RESPIRATORY SYSTEM 

an inflammation of the mucous membrane of the larger bronchi and 
of the pleura. The frequency and severity of the pleurisy is a peculiarity 
of the lesion in children. 

In the first stage, that of congestion, the portion of lung involved is 
dark-colored, heavy, and edematous, and shows under the microscope a 
serous and cellular exudation into the air vesicles, with swelling of the 
epithelial cells lining the alveoli. 

In the second stage, that of red hepatization, there is usually some 
exudation upon the pulmonary pleura, generally a thin layer of fibrin, 
giving it a dull look. The lung itself is of a uniform dark-red color. It 
is solid and cuts like liver. It looks as if it had been inflated to its 
utmost extent and then injected with a material which had solidified. 
The consolidated area is sharply defined. Under the microscope the air 
vesicles are seen to be distended with an exudation which is chiefly fibrin, 
but with some leucocytes, red blood-cells, and desquamated epithelial 
cells. The cells are chiefly leucocytes, and are usually more abundant 
than in the pneumonia of adults. 

In the third stage, that of gray hepatization, the lung is more moist, 
and the inflammatory products are partly decolorized. This change 
takes place irregularly throughout the lung, giving it a mottled 
appearance. 

The fourth stage, that of resolution, follows gray hepatization, and 
consists in the degeneration and liquefaction of the products of inflam- 
mation, which are ultimately carried away by the lymphatics in great 
part, only a small amount being pushed out into the bronchi and re- 
moved by coughing. 

The duration of the stage of congestion is from a few hours to sev- 
eral days; that of the stage of red hepatization from two days to two 
or three weeks. This is the condition in which the lung is most often 
seen at autopsy. The stage of gray hepatization is commonly shorter. 
Eesolution usually begins when the temperature falls to normal, but 
occasionally it may be delayed for several days. It is generally complete 
in about a week. 

Variations in the Lesions. — (1) Instead of clearing up at the usual 
time, the lung may remain consolidated for several weeks, and then re- 
solve. (2) The stage of gray hepatization may be followed by a great 
exudation of pus cells, which may everywhere infiltrate the affected 
lung; or these may be circumscribed so as to form a single large 
abscess or many small ones. (3) There may be small areas of gan- 
grene. All these three conditions are rare in young children. (4) 
There may be excessive pleurisy, or pleuropneumonia. This is found 
at autopsy in about one-half the cases, and will be separately considered 
elsewhere. 



LOBAR PXEUMOXIA 



529 



The lesions in the other organs are for the most part due to the 
pneumococcal. There may he pericarditis, especially with pneumonia of 
the left side if complicated by excessive pleurisy. This is seen even in 
infants. The pericardial inflammation closely resembles that of the 
pleura. There is a very abundant exudation of fibrin and pus, coating 
both surfaces of the pericardium. Acute meningitis is rather rare. It is 
an acute purulent inflammation, with a very abundant exudation of 
greenish-yellow fibrin and pus, chiefly at the convexity. Less frequently 
peritonitis is present. Acute parotitis and acute arthritis are seen as 
rare complications of pneumonia. In most of the complicated cases the 
other lesions are second to those in the lungs ; but they may begin simul- 
taneously with, or even precede, the pneumonia. In severe and rapidly 
fatal cases with meningeal or peritoneal complications, a general pneu- 
moeoecus septicemia is usually present. 

The heart is generally found in diastole, with the cavities, especially 
those of the right side, distended with soft clots. There may be found 
ante-mortem thrombi, which may extend into the pulmonary artery or 
the aorta. 

Symptoms. — (1) The Typical Course. — A child three or four years of 
age, after a few hours of slight indisposition, is suddenly taken with 
vomiting, followed by a rapid rise in temperature. He is dull and heavy, 
complains of headache and general weakness, refuses food, and is easily 
persuaded to remain in bed. He has the appearance of being quite ill, 
even after a few hours. Occasionally sharp pain in the side is complained 
of. The skin is dry; there are marked 
thirst, restlessness, and the other symptoms 
which accompany fever. The temperature 
is found to be 104° F., or even higher; the 
respirations 40 to 50 a minute; the pulse 
full, strong, and 120 to 130. On the second 
day the patient is no better. The tempera- 
ture remains high; the tongue is coated; the 
anorexia continues; the pain is more severe; 
<nu o]i is present and may be quite frequent. 

After the second or third day the patient 
is usually more comfortable, and sleeps bet- 
ter, but may be disturbed by the cough. At 
times there is restlessness, and at night there 
may even be slight delirium. The respira- 
tion continues rapid and the temperature 

high. These general symptoms show very little change until the sixth or 
seventh day, when, after a long sleep, which has been more natural than 
before, the patient Makes, decidedly improved as to all his symptoms. 



1U5° 
101° 
103° 
102° 
101° 
100° 
09° 


|1:2|3:15 67« 


A 


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Fig. 64. — Typical Tempera- 
ture Curve of Lobar 
Pneumonia. History . — 
Male, three years old; in fair 
condition ; sudden onset ; 
signs of consolidation — 
bronchial respiration and 
voice, and dulness — over left 
lower lobe behind, not dis- 
tinct until the morning of the 
fifth day. On the seventh 
day the Lung was resolving. 



530 DISEASES OF THE RESPIRATORY SYSTEM 

There is less fever, and the temperature continues to fall rapidly until 
it touches the normal line, or it may even go below this. As the fever 
subsides the pulse drops to 90 or 100, and the respirations to 25 or 30 a 
minute. The appetite soon returns, and convalescence is usually rapid. 
In a week the patient is out of bed, and in a week or two more he is out 
of doors. This is the course seen in fully two-thirds of all the cases of 
lobar pneumonia at this age. 

(2) Pneumonia of Short Duration. — Instead of running the usual 
course of from five to eight days, cases are seen in which the duration is 
only three or four days, although the physical signs indicate that the 
process in the lung passes through the usual stages. These differ from 
the ordinary type chiefly in their duration. They are always mild. 

(3) Abortive Pneumonia. — This form of the disease is rarely seen 
in hospitals, but it is not infrequent in private practice where the phy- 
sician is summoned at the earliest signs of illness. The onset is precisely 
like that of ordinary pneumonia, and may even be as severe as the aver- 
age case. The physical examination of the chest gives all the signs of 
the first stage of the disease, but on the second or third day the physician 
is greatly surprised to find that the temperature has fallen to normal, 
and that all the physical signs have disappeared. The process in such 
cases does not seem to go beyond the first stage of congestion; there is 
no evidence of hepatization of the lung. The course is often such as to 
lead the physician to the opinion that he has made a mistake in his 
diagnosis. This type of pneumonia corresponds with abortive types of 
other infectious diseases so frequently met with in children. The tem- 
perature curve in such a case is shown in Fig. 67. The diagnosis of 
these cases is always attended with some uncertainty. There can be no 
doubt that many of the unexplained high temperatures of brief duration 
which are seen in children are from this cause. Exactly why it is that 
the disease sometimes terminates in this way can not always be explained. 
It may be because the resistance of the patient is greater than usual, or 
the virulence of the pneumococcus is less. 

(T) The Prolonged Course. — Although usually lasting about a week, 
it is not rare for pneumonia to continue ten, twelve, or even fifteen days. 
This prolonged course is usually due to the fact that the disease spreads 
from one part of the lung to another, or even to the opposite lung, in- 
volving in succession two, three, or more lobes. This is sometimes known 
as "creeping" pneumonia; it is always severe and the outlook is gen- 
erally unfavorable. A prolonged temperature with physical signs lim- 
ited to a single lobe should always suggest complications, most frequently 
empyema, occasionally pericarditis. 

(5) Hyperacute Pneumonia. — Pneumonia may very rarely be fatal 
in the first forty-eight hours. The onset is sudden, frequently with con- 



LOBAR PNEUMONIA 531 

vulsions. The prostration is extreme and in a few hours the child may 
be pulseless. Delirium or deep coma is the rule. There may be no 
cough and no symptoms or physical signs pointing to a pulmonary lesion. 
The respiration may be slow and very deep like the breathing in the 
air hunger of acidosis. The system seems overwhelmed by the intensity 
of the toxemia. Unless one has seen autopsies upon patients with this 
form of pneumonia it seems impossible to believe that the course could 
differ so from the type of disease usually observed. The diagnosis can 
only be suspected unless consolidation of the lung can be made out. 
This type of pneumonia is not found in infancy. In a few such cases 
a complicating acidosis has been shown to be present by laboratory tests. 

(6) Cerebral Pneumonia. — This term was first applied by Eilliet 
and Barthez to cases of pneumonia in which the cerebral symptoms pre- 
dominate. They will be considered later. 

Onset. — Prodromal symptoms of more than a few hours' duration are 
quite rare. The onset of lobar pneumonia is almost invariably abrupt, 
with well-marked symptoms — vomiting, diarrhea, chill, or convulsions. 
Vomiting is altogether the most frequently seen. In summer particu- 
larly, there may be vomiting and diarrhea. A distinct chill is rare in a 
child under five years of age, and is not very common even in older chil- 
dren. Convulsions are not very infrequent, being seen in about five per 
cent of the cases. Their occurrence depends upon the suddenness of the 
invasion and the susceptibility of the patient. 

Cough. — This is present in most of the cases throughout the disease, 
but often is not marked for the first day or two. It is seldom a dis- 
tressing symptom. A disposition to suppress the cough on account of 
pain is very frequently noticed. 

Expectoration. — This is rarely seen in early childhood, and practi- 
cally never under five years of age. Children of ten or twelve may have 
the same expectoration as adults — white and viscid, or brownish-red early 
in the disease, yellow and abundant toward its close. This shows the 
presence of the pneumococcus in great numbers. 

Pain. — Headache and general muscular pains in the back and ex- 
tremities are frequent during the invasion. The characteristic pain, how- 
ever, is pleuritic. It is not necessarily felt in the region of the affected 
lung, and often not in the chest at all. It is frequently referred to 
the loin, the epigastrium, or to any region to which the intercostal 
nerves arc distributed. Pain in the right iliac fossa associated with 
extreme tenderness and some rigidity may lead to the suspicion of 
appendicitis when in reality the pain is referred from the inflamed 
pleura. 

Prostration. — This is one of the characteristic features of pneumonia. 
The patient is generally willing to go to bed on the first day of the 



532 



DISEASES OF THE RESPIRATORY SYSTEM 



107° 


1 


2 


3 


4 1 5 





7 


1 9 10 11 


12 


13 1 


i 15 


16 


17 


18 


19 120 


106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
































1 








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98° 
97° 






















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Fig. 65. — Lobar Pneumonia with Remittent Tem- 
perature. History. — Female, eighteen months 
old; in fair condition; sudden onset; repeated 
examinations of chest made, but no abnormal 
signs until the ninth day, when there were very rude 
respiration and slight dulness at the right apex, in 
front; on the twelfth day all the signs of consoli- 
dation at the same point, no rales; four days after 
the crisis the lungs were clear. 



attack, and shows little desire to leave it while the disease continues. 
Ambulatory cases are not common in children. 

Respiration. — This is always accelerated, and generally out of propor- 
tion to the pulse. The 
normal ratio of the res- 
piration to the pulse is 
one to four; in pneu- 
monia, frequently one to 
two. The respiration is 
not labored and not quite 
panting, although this 
term is sometimes used 
to describe it. It is 
jerky. There is a short 
inspiration, then a mo- 
mentary pause, followed 
by a quick expiration, 
which is accompanied by 
a short moan. This expiratory moan is very characteristic. The rapidity 
of respiration is usually in proportion to the amount of lung involved, 
but it is also modified by the temperature, as the respirations often drop 
from 60 to 30 in the 
course of a few hours at 
the crisis. 

Pulse. — In the early 
part of the disease this 
is frequent, full, and 
strong, from 120 to 150 
a minute. Later it may 
be weak, small, compres- 
sible, and sometimes ir- 
regular. It is much more 
rapid in the child than in 
the adult, 160 and 180 
being often seen in cases 
not especially severe. The 
pulse rate is of less im- 
portance than its charac- 
ter. 

Te mperat lire. — The typ n 
(Fig. 64) is characterized by 

and by daily fluctuations generally within the limits of two or three 

mal, 



1C?° 


1 


2 


3 


i 


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6 


7 


8 | 9 1 10 


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13 


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15 


16 


17 


IS 


19 


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105° 
101° 
103° 
102° 
101° 
100° 
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97° 

95° 

91° 




























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Fig. 66. — Lobar Pneumonia with Subnormal Tem- 
perature after the Crisis. Historxj. — Female, 
nineteen months old ; fair] y heal r hy ; sudden onset ; 
symptoms typical but physical signs delayed; con- 
solidation in left mammary region on the eighth 
day; on the ninth in right lung middle lobe; on the 
eleventh day a pseudocritical drop followed after 
twenty-four hours of apyrexia by a further rise, 
which was accompanied by signs of extension of the 
disease in the right lung. Resolution rapid after 
crisis. 



ill temperature curve of lobar pneumonia 
an abrupt rise usually to 10-t° or 105° F., 



degrees until the crisis, at which time the temperature falls to noi 



LOBAR PNEUMONIA 



533 



106° 
105° 
104' 
103- 
102- 
101° 
100 ' 
99 J 




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11 12 


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15 


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usually in the course of twenty-four hours. After this time it does not 
go above the normal line. Such a curve is seen in the majority of cases 
over three years of age. 

In children under three years of age it is not uncommon for the tem- 
perature to be of a more or less remittent type (Fig. 65). 

These wide fluctuations often lead to great difficulty in diagnosis, 
particularly if the physical signs appear late, as they not infrequently 
do. It is probable that most of them are to be explained as mixed 
infections. 

The chart shown in Fig. 66 illustrates three features which 
are often seen in pneumonia: (1) A temperature which early in the 
disease is steadily high and 
as the day of crisis ap- 
proaches becomes remittent; 
(2) a secondary rise after 
being normal for twenty-four 
hours, which was due in this 
instance to an extension of 
the disease to a new part of 
the lung; (3) a fall to a 
point considerably below 
normal at the time of the 
crisis. In this case the tem- 
perature fell in the course of 
eighteen hours from 105° to 
95° F., and later still lower; 
it was two days before it fi- 
nally remained at the normal 
point. A fall to 96.5° or 
97° F. at the time of crisis is not uncommon. 

In the foregoing cases the fever terminated by crisis. In Fig. 67 is 
shown one ending by lysis. This is a mode of termination much more 
frequent in young children than in those who are older. Thus, in 93 
of our own cases, nearly all of which were in children under three years 
of age, the fever ended by crisis in 49, and by lysis in 44 ; while in 552 
collected cases, the majority of which were in older children, 396 ended 
by crisis, and 126 by lysis. 

The table on the following page shows the day of crisis in 567 cases 
of lobar pneumonia in children who recovered. From this it will be 
seen that the most frequent critical day is the seventh, and that in sixty- 
six per cent of the cases it was from the fifth to the eighth day. The 
causes of a post-critical rise in the temperature are chiefly two — exten- 
sion of the disease to a new area, or the development of pleurisy, which is 



Fig. 67. — Abortive Pneumonia in Left Lung, 
followed by typical pneumonia in rlght 
Lung, Terminating by Lysis. History. — 
Male, seventeen months old, healthy; sudden 
onset, on the second day disseminated fine 
rales in both lungs behind, and over left lower 
lobe very feeble respiration, high-pitched — 
i. e., some bronchitis, with congestion (?) of 
left base. On the third, fourth, and fifth 
days, general symptoms gone and signs nearly 
disappeared. On the sixth day all symptoms 
of pneumonia, and on the seventh distinct 
consolidation of right base, rest of chest 
clear. Subsequent course typical, resolution 
rapid and complete. 



534 DISEASES OF THE RESPIRATORY SYSTEM 

apt to be purulent. Less frequently it is due to otitis, meningitis, peri- 
carditis, or gastro-enteritis. In fatal cases the temperature is generally 
high until the end. In general, it may be said that the temperature is 
considerably higher in children than in adults; in the majority of cases 
it reaches 105° F., the usual range being from 102° to 105° F. In 15 
of 137 cases, or eleven per cent, it reached 100° F. or over. 



Second day 


3 ( 


The 

jases 

u 
a 
u 

a 
u 
a 
u 
a 


Day 


of Crisis 

Eleventh dav 

Twelfth 


18 cases. 


Third " . 


22 


7 " 


Fourth " . 


43 


Thirteenth " 


8 " 


Fifth " 


88 


Fourteenth " 


7 " 


Sixth " 


83 


Fifteenth " 


1 case. 


Seventh " 


132 

73 


Eighteenth " 


3 cases. 


Eighth " . 


Twenty-first " 


1 case. 


Ninth " . 


55 


Twentv-sixth " 


1 " 


Tenth " 


...... 22 







Gastro-enteric Symptoms. — These are more common in infants than 
in older children. At the onset there is frequently vomiting, some- 
times also diarrhea. A continuance of the vomiting is rare, and is 
generally due to improper feeding or medication. It may be a very 
serious complication. Diarrhea is also rare, except at the onset and 
in summer cases. Great tympanites is a distressing symptom, and when 
present, it is a bad prognostic sign. Throughout the disease there are 
anorexia, coated tongue, and the usual symptoms of high fever. 

Nervous Symptoms. — Cerebral symptoms are frequent and very often 
misleading. Pneumonia is often ushered in by convulsions, which may 
be repeated two or three times in the course of the first twenty-four 
hours. They are sometimes followed by drowsiness or stupor, sometimes 
4>y active delirium. Cerebral symptoms may predominate for several 
days. There may be opisthotonus, dilated or contracted pupils, irregular 
pulse, retracted abdomen, and, in fact, almost every symptom of menin- 
gitis. Lumbar puncture in these cases usually shows an excess of cerebro- 
spinal fluid under high tension and it may contain a few pneumococci. 
Occasionally the decubitus en cliien de fusil, or gun-hammer position, is 
assumed. These are often described as cases of cerebral pneumonia, and 
in many of them pneumonia is not suspected until the fourth or fifth 
day of the disease, sometimes not until the crisis occurs, when the rapid 
disappearance of all these nervous symptoms indicates their origin. 
Early convulsions are not generally followed by an especially severe type 
of the disease, only one of seven such cases proving fatal. On the other 
hand, cases with late convulsions are usually fatal, as they indicate either 
a very severe form of the disease or the development of a serious com- 
plication, usually meningitis. 

Delirium is much more frequent than convulsions, and is seen in 



LOBAR PXEOIOXIA 535 

nearly one-fourth of the cases. Generally it is slight and noticed only 
at night or when the temperature is very high. It is most pronounced 
at the height of the disease. Other nervous symptoms belonging to the 
typhoid state are occasionally seen, but only in the most severe forms of 
the disease. 

It is impossible to establish any relation between the seat of the 
disease in the lungs and the occurrence of cerebral symptoms. They 
are more frequent in children under five years than in those who 
are older, and depend upon the suddenness of the invasion, the in- 
tensity of the infection, and the susceptibility of the child. Late in 
the disease they may indicate exhaustion, toxemia, or complicating 
meningitis. The usual nervous symptoms — restlessness, headache, sleep- 
lessness, etc. — are nearly always proportionate to the height of the 
temperature. 

Urine. — Throughout the febrile period of the disease the urine is 
scanty, high-colored, with a high specific gravity, usually loaded with 
urates and with marked diminution of the chlorids. A moderate acetone 
reaction is very common. In a small proportion of cases a trace of 
albumin may be found, and occasionally a few hyaline casts. Evidences 
of serious renal disease are seldom found in lobar pneumonia in early 
life. 

Shin. — The face, in pneumonia, is usually flushed, sometimes on both 
sides and sometimes only on one; in other cases it is pale, but not in- 
dicative of pain. Cyanosis is rare except toward the close of the disease 
and is usually a sign of respiratory failure. Herpes of the lips or face 
is quite frequent. 

Blood. — A marked polymorphonuclear leucocytosis is a characteristic 
feature of lobar pneumonia ; the exceptions are in very mild cases or very 
severe infections with little or no reaction. The increase begins shortly 
after the onset and continues during the stage of exudation, generally 
reaching its maximum shortly before the crisis, when it declines rapidly. 
The usual number of white cells in an average case of pneumonia in 
a young child is from 25,000 to 40,000, but it is not rare for the count 
to run up to 50,000 or even 60,000. We have seen it over 100,000 several 
times. The absence of leucocytosis in a strong child who is acutely ill 
is always strong presumptive evidence against pneumonia. A well- 
marked leucocytosis is of much value in differentiating pneumonia from 
typhoid fever. Positive blood cultures were obtained in the Babies' Hos- 
pital in 1L per cent, of 108 cases studied. Otten found almost exactly 
the same proportion in a study of 70 cases. These observations indicate 
that positive cultures are much less frequent than in the pneumonia 
of adults. 

Physical Signs. — The earliest signs in pneumonia are due to the 




Fig. 68. — First Stage. Congestion of left 
lower lobe, with crepitant rales. Feeble 
breathing of a rude character, with slight 
dulness. 



Fig. 69. — In the center of the area, a small 
spot of pure bronchial breathing and voice; 
surrounding this an occasional crepitant 
rale, with bronchovesicular breathing and 
slight dulness. 




Fig. 70. — Second Stage. Complete consolidation of left lower lobe. Pure bronchial breathing and 
bronchial voice; marked dulness; increased vocal fremitus, and at the lower part a few friction 
sounds. 

Note. — During resolution the signs take the inverse order: those of Fig. 70 give place to 
those of Fig. 69, and these in turn to those of Fig. 68. In addition, many coarse rales may be 
heard. 



536 



LOBAR PNEUMONIA 



53" 



acute congestion of the affected lung or lobe, in consequence of which 
less air enters this portion and more air the rest of the lungs. Percus- 
sion gives diminished resonance or slight dulness, often of a somewhat 
tympanitic character over the affected area, and exaggerated resonance 
over the remainder of this lung and over the opposite lung. Ausculta- 
tion over the affected lobe gives feeble respiratory murmur, rather high 
in pitch; sometimes there may be so nearly an absence of all breath- 
sounds as to suggest fluid. The normal respiratory murmur over the 
healthy portions of the lungs is intensified. In children this exag- 
gerated breathing is not infrequently mistaken for bronchial breathing, 




Fig. 71. — Lobah Pneumonia. Child 2\ years old. Lobar pneumonia of right upper 
and middle lobes, at the height of the disease with all the usual signs of consolidation. 



and the physician may be led into the error of locating the pneumonia 
upon the wrong side. Exaggerated breathing differs little from nor- 
mal breathing except in intensity. Bronchial breathing is higher in 
pitch, tubular in character, and is heard with nearly equal intensity., 
both on expiration and inspiration. If the chest is frequently aus- 
cultated, crepitant or fine subcrepitant rales may usually be heard at some 
period at the end of full inspiration, but often they are present but for 
a few hours, and they may be missed altogether. (Figs. 68, 69, 70.) 

A study of cases of lobar pneumonia by the X-ray shows that con- 
solidation occurs early, and that it first affects the surface of the lung, 
gradually extending inward as the disease progresses (Fig. 71). Bron- 
chial breathing is not usually obtained until the consolidation has reached 
the hilus of the lung. Feeble breathing and slight dulness occur earlier. 



538 DISEASES OF THE RESPIRATORY SYSTEM 

In the second stage, that of consolidation, no air enters the air vesi- 
cles of the affected portion of the lung. There is found here exaggerated 
vocal fremitus, and marked dulness, but very rarely flatness. Over 
the rest of this lung there is exaggerated, sometimes even tympanitic, 
resonance; this is especially frequent at the apex of the lung in front, 
when there is consolidation at the base behind. Under these conditions 
cracked-pot resonance may sometimes be obtained. Over the healthy 
lung there is exaggerated resonance. Over the consolidated portion 
there is bronchial breathing and bronchial voice, the area over which 
they are heard being sharply defined. Kales are usually absent, but there 
may be pleuritic friction sounds. 

In the stage of resolution there is a gradual disappearance of the 
signs of consolidation. - The pure bronchial is replaced by broncho- 
vesicular breathing, the vesicular element gradually predominating. 
Moist rales of all varieties are heard. Usually the most persistent signs 
are slight dulness or diminished resonance, with a respiratory murmur 
which is feebler than normal and a little higher in pitch ; sometimes there 
are also dry friction sounds. These signs may persist for two or three 
weeks. 

Exceptional Physical Signs. — While in the majority of cases the signs 
of consolidation are distinct on or before the fourth day, in not a few 
they may be delayed much longer. Of eighty-two cases in which the day 
was noted on which consolidation was found, it was not until the fifth 
day or later in one-fourth the number. In six of them, although care- 
fully and repeatedly examined, no consolidation was found until the 
seventh day or later and in one case not until the twelfth day. These 
cases of delayed or concealed physical signs have often been regarded as 
examples of central pneumonia. That pneumonia may exist only in the 
center of a lung for a number of days is extremely improbable. At 
autopsy we have very frequently seen superficial pneumonia but never 
central lobar pneumonia. X-ray studies have shown conclusively that 
with a superficial consolidation no bronchial breathing may be heard 
even though the consolidation may be fairly extensive. When the proc- 
ess extends toward and reaches the hilus of tne lung bronchial breathing 
is readily heard. It is the superficial pneumonia, then, that escapes 
detection rather than the central. There are, however, two regions in 
which pneumonia may exist and yet not be accessible by our means of 
physical examination, viz., at the apex of the lung in the part covered by 
the shoulder, and along the posterior border of the lung where it lies 
against the vertebrae. It is quite common in cases with late physical 
signs that the first distinctive evidences of disease are found high in the 
axilla, or beneath the clavicle in front, and these regions should be closely 
watched in all doubtful cases. 



LOBAR PNEUMONIA 539 

Complications. — The occurrence of dry pleurisy over the consolidated 
portion of the lung is so constant that it can hardly be considered a com- 
plication. A slight serous exudation of two or three ounces is very 
common and often develops rapidly. In the most severe cases of pleurisy 
there is an excessive exudation of fibrin and pus. This has occurred 
in about eight per cent of our cases. This variety is known clinically 
as pleuropneumonia, and will be considered separately. Pericarditis 
is uncommon. It is seen more often in infants than in older children. 
It most frequently develops at the height of the pneumonia rather 
oftener when this affects- the left lung than the right; it occurs in pleuro- 
pneumonia much more often than in the simple form. The pericarditis 
is usually of the fibrinopurulent type. It may sometimes be discovered 
by physical signs; but rarely gives rise to any new symptoms. Endo- 
carditis is extremely rare, though now and then it occurs upon valves 
previously the seat of a chronic lesion. Meningitis is rare, and generally 
develops late in the disease. It is nearly always ushered in by repeated 
attacks of vomiting or convulsions. Its course is short and progressive. 
Peritonitis causes few new symptoms except abdominal distention, pain, 
and tenderness. Parotitis and arthritis are very rare and are easily 
recognized. 

Course and Termination. — In the great majority of cases lobar pneu- 
monia terminates either in perfect recovery or in death. When ending 
in recovery, resolution commonly begins immediately upon the cessation 
of the fever, and is complete in about a week. Delayed resolution is not 
common in children ; chronic pneumonia and tuberculosis are rare 
sequelae, but empyema is very frequent. Its symptoms sometimes develop 
immediately after the pneumonia, the temperature continuing high; or 
there may be an interval of a few days before the development of the 
pleural symptoms. Some pleuritic adhesions probably remain in every 
case in which there has been much dry pleurisy, and when severe and ex- 
tensive, these may be the cause of subsequent symptoms, like any other 
dry pleurisy. 

Death from uncomplicated pneumonia may be due to exhaustion, or 
to circulatory failure, with or without failure of the respiration. The 
signs of circulatory failure sometimes develop quite rapidly in cases 
which -are apparently doing well. The symptoms are: coldness of the 
hands and feet, then of the legs and arms; a rapid, compressible, and 
sometimes irregular pulse; muscular weakness and pallor, but usually 
no cyanosis. The symptoms of respiratory failure are : very rapid super- 
ficial respirations, sometimes 100 a minute; blueness of the lips and 
finger nails; often a leaden hue of the whole body; there are loud 
tracheal rales, and recession of all the soft parts of the chest on 
inspiration. 



540 



DISEASES OF THE RESPIRATORY SYSTEM 



Death may occur early in the disease, when the pnenmonia has 
spread rapidly, involving both lungs. In most of the uncomplicated 
fatal cases, death results from failure of the circulation at about the end 
of the first week. In the complicated cases death usually occurs in the 
secorid week; but we have known fatal meningitis to develop as late as 
the end of the fourth week. 

Diagnosis. — The most characteristic clinical and pathological differ- 
ences between broncho- and lobar pneumonia are shown in the following 
table : 



BRONCHOPNEUMONIA 

1. Often secondary. 

2. Under two, chiefly under one 
year. 

3. Occurs more frequently in del- 
icate and debilitated children. 

4. Bacteria — in primary cases, usu- 
ally the pneumococcus ; in secondary 
cases, usually mixed infection. 

5. Products of inflammation chiefly 
cellular; process often diffuse. 

6. Onset often gradual, sometimes 
insidious, especially when secondary. 

7. No typical course; fever often 
lasts three or four weeks; rarely ter- 
minates by crisis. 

8. Involves both lungs as a rule, 
most frequently lower lobes posteriorly. 

9. Signs of bronchitis mingled with 
those of consolidation; rales in other 
parts of the same lung, or in the oppo- 
site lung, throughout the disease. 

10. Consolidation later — fourth to 
seventh day: there may be none; apt 
to be incomplete; shades off gradually. 

11. Resolution slow, one week to 
two months; often incomplete; strong 
tendency to become chronic. 

12. Relapses and second attacks 
frequent. 

13. Sequelae : Empyema, chronic in- 
terstitial pneumonia, sometimes tuber- 
culosis. 

14. Prognosis always serious from 
the age and the circumstances in 
which disease occurs. 

15. Hospital mortality 50 per cent of 
primary cases, 65 per cent of all cases. 



LOBAR PNEUMONIA 

1. Almost always primary. 

2. Most common between three and 
eight years. 

3. More often in those previously 
healthy. 

4. The pneumococcus, very often 
alone. 

5. Chiefly fibrin; process circum- 
scribed. 

6. Onset sudden, with well-marked 
symptoms. 

7. Typical course; crisis, usually 
from fifth to eighth day. 

8. Usually one lobe or a part of a 
lobe; left base most frequently, right 
apex next. 

9. Rales only early, and during reso- 
lution; frequently no signs in opposite 
lung. 

10. Consolidation earlier; second or 
third day. Consolidation complete; 
area usually "sharply defined. 

11. Resolution rapid, usually com- 
plete within a week. 

12. Both are rare. 

13. No sequelae except empyema. 



14. Prognosis good; rarely fatal ex- 
cept from complications — empyema, 
meningitis, pericarditis. 

15. Mortality about 4 per cent of 
all cases. 



LOBAR PNEUMONIA 541 

C 

In the majority of cases the symptoms are plain and the physical 
signs so typical that it is difficult to overlook pneumonia if any degree 
of care is used in the examination of the patient. The difficulties in diag- 
nosis are due to the great variation in the general symptoms, and to the 
late appearance of the physical signs. The error usually made is to mis- 
take pneumonia for some other disease, rather than to mistake some 
other disease for pneumonia. On account of its frequency in children, 
pneumonia should always be excluded before accepting any other ex- 
planation of a continuously high temperature. The rule should be fol- 
lowed, in all cases of acute illness, of making a thorough examination of 
the chest daily until the diagnosis is clear. If, to high temperature, 
rapid respiration and marked leucocytosis are added, one should always 
suspect pneumonia, no matter what the other symptoms may be. It 
not infrequently happens that the general symptoms are quite charac- 
teristic and yet the physical signs appear late. In such cases pneumonia 
should always be looked for high in the axilla or just beneath the clavi- 
cle, since it is particularly in the cases of apex pneumonia that this 
obscurity is likely to exist. 

In their onset, scarlet fever, tonsillitis, and gastro-enteritis may all 
resemble pneumonia. Scarlet fever is recognized by the sore throat and 
the characteristic eruption on the second day; tonsillitis, by the local 
symptoms. In infancy, pneumonia often begins with vomiting and 
sometimes there is also diarrhea, which may lead one to mistake the 
disease for gastro-enteritis. The constitutional symptoms of influenza 
often closely resemble those of pneumonia; the diagnosis is frequently 
in doubt for several days until definite physical signs of pneumonia 
make their appearance. From all other general diseases, pneumonia is 
to be differentiated by the physical signs. 

Pneumonia with marked cerebral symptoms sometimes resembles 
cerebrospinal meningitis. In both we may have the abrupt onset, con- 
vulsions, delirium or stupor, opisthotonus, prostration, and marked leu- 
cocytosis. The only positive means of differential diagnosis are by the 
physical signs in pneumonia, and the findings from lumbar puncture in 
cerebrospinal meningitis. 

The question sometimes arises in pneumonia with cerebral symptoms, 
whether or not pneumococcus meningitis also exists. If the nervous 
symptoms are present from the beginning, there is probably no menin- 
gitis. If they develop suddenly during the course or toward the close 
of the disease, meningitis should be suspected. The only positive means 
of differentiation is by lumbar puncture. 

Lobar pneumonia is to be differentiated from a pleuritic effusion. 
The most common mistake is to confound empyema with unresolved 
pneumonia. In pneumonia rarely if ever do the signs point to involve- 
19 



542 DISEASES OF THE RESPIRATORY SYSTEM 

merit of an entire lung. There is increased vocal fremitus, dulness, 
bronchial voice and breathing, and occasional rales or friction sounds. 
In empyema the whole lung is often affected, there is displacement of 
the heart, flatness on percussion, diminished or absent vocal fremitus, 
and although bronchial voice and breathing are present, they are usually 
distant and feeble. There are no rales or friction sounds. In doubtful 
cases an exploratory puncture should always be 'made. Serous effusions 
give the same physical signs as empyema. 

The X-ray may be of marked assistance in diagnosis. The shadow 
of consolidation in lobar pneumonia is usually clear and sharply cir- 
cumscribed. It is often wedge shaped as shown in Fig. 71. 

Prognosis. — There is probably no disease in which the patient ap- 
pears so ill, and yet so often recovers completely, as lobar pneumonia 
in children over three years old. Of 1,295 collected cases, chiefly from 
hospital practice, there were but 39 deaths, a mortality of three per cent. 
In 187 cases of our own there were 21 deaths, a mortality of eleven per 
cent. In only one of the fatal cases was the child over two years old. The 
difference between the mortality among our cases and the general mortal- 
ity given, is due to the fact that a large proportion of the first group were 
observed in children under two years, while of the collected cases, the 
vast majority were in older children. Combining the above figures, we 
have a total of 1,482 cases with 60 deaths, a mortality of four per cent. 
In nearly all our cases death was due either to complications or to very 
extensive disease, as when both lungs were involved, or nearly the whole 
of one lung. In only one case was an uncomplicated pneumonia of a 
single lobe fatal. 

The prognosis depends upon the age of the patient, the intensity of 
the infection, as shown by the temperature, nervous symptoms and pulse, 
the presence or absence of complications, and the extent of the local 
disease. These factors are to be taken into consideration rather than 
any special symptoms. Early convulsions do not materially affect the 
prognosis. Late convulsions are always very unfavorable. 

The occurrence of vomiting, diarrhea, or marked tympanites late in 
the disease is always unfavorable. 

A temperature range between 102° and 105° F. is the rule, and 
within these limits the fever does not affect the prognosis. Even very 
high temperature does not increase the danger from the disease as much 
as might be expected. Of fifteen cases in which the temperature reached 
106° F. or over, all but three recovered; while of six cases in which it 
was 106.5° or over, only one died. The highest recorded temperature in 
our cases — 107.5° F. — was in a patient who recovered. A transient rise, 
even though the temperature may go very high, is seldom serious. 
Much more serious is a fever which remains steadily above 105° F., as 



LOBAR PNEUMONIA 543 

iii most cases this accompanies either very extensive disease or pleuro- 
pneumonia. The continuance of the fever after the tenth day is a bad 
symptom; for, although the crisis may be postponed until the twelfth 
day and occur normally, such a prolonged temperature is an indication 
of a new focus of disease or the development of complications. In a 
severe attack, the extension of the disease to another lobe after the fifth 
day is unfavorable. If resolution does not begin soon after the tem- 
perature becomes normal, the development of empyema, or some other 
pulmonary complication, should be apprehended. 

The results of blood cultures have some prognostic value. Of 108 
hospital cases the mortality of 15 with positive cultures was 33 per cent; 
of 93 with negative cultures it was but 8 per cent. 

Treatment. — The specific treatment of lobar pneumonia has not yet 
reached a point where it is to be advised with children. In considering 
the management of this disease several cardinal facts are to be kept in 
mind. It is a self-limited disease, having a strong tendency to recovery 
in the great majority of cases regardless of the treatment adopted. The 
fatal cases are almost always in children under two years of age; the 
rare deaths in older ones are usually due to complications. There is 
as yet no treatment which can be relied upon to abort an attack of pneu- 
monia or shorten its course. It follows, therefore, that the indications 
are, so far as possible, to make the patient comfortable during his 
illness, to watch for complications, and to treat the individual symptoms 
as they arise. 

In the majority of cases, hygienic treatment is all that is required. 
The patient should be kept in bed, no matter how mild the attack; he 
should be disturbed as little as jxtssible. Most children with pneumonia 
get too much treatment. There seems to be a decided advantage not 
only in fresh air, but in cold air. Patients in cold rooms sleep better, 
cough less, and altogether seem more comfortable than when care- 
fully housed to prevent their "taking cold." Wide-open windows arc 
desirable even though the room temperature is constantly as low as 
50° F. The patient should be properly protected by blankets, flannel 
wrapper, woolen stockings, and at times a hot-water bag at his feet. 
Food should be given at regular intervals, usually not oftener than 
every four hours. It should not be forced when the patient is suffering 
only from thirst, especially early in the attack, when the appetite is 
often completely lost. Water should be allowed freely at all times. 

These measures, careful nursing, an occasional dose of codein (gr. 
^ to a child of three years) when the patient is very restless ; fretful, or 
sleepless, an ice-cap to the head, and cold sponging when the tempera- 
ture makes him uncomfortable, are usually all that is necessary, except 
to keep a sharp lookout for complications. 



544 DISEASES OF THE RESPIRATORY SYSTEM 

Special symptoms may require treatment. When not severe, the 
nervous symptoms may be controlled by codein alone or in combination 
with small doses of phenacetin or the bromids. Sometimes sponging 
with tepid water is better than drugs. Severe nervous symptoms, such 
as delirium, stupor, great restlessness with impending convulsions, when 
associated with high temperature, call for ice to the head, cold sponging, 
or the cold pack or bath: Pain, if moderate, may be relieved by counter- 
irritation, by a mustard paste, by dry cups, an ice-bag, or by a hot poul- 
tice; if severe, codein may be used in addition. The cough is rarely 
severe enough to require treatment. When it is so severe as to prevent 
sleep, small doses of Dover's powder or codein should be given. Anti- 
pyretic measures are not necessarily called for even if the temperature 
is very high. Some nervous children are less disturbed by the tempera- 
ture than by the means used to reduce it. Under such conditions the 
temperature should be closely watched, but not necessarily interfered 
with unless other symptoms develop. The nervous symptoms are a bet- 
ter guide than the thermometer to the use of antipyretics. Cold we be- 
lieve to be the safest and most certain antipyretic we possess. - It may 
be used as a cold sponge bath, the cold pack or an ice-bag to the chest. 
There is no objection to the bath except the prejudice of the laity. 
While cold is applied to the trunk the extremities should be closely 
watched, and heat applied if necessary. The duration of the pack or 
bath, and the frequency of their use, will depend upon the individual case. 
In the majority of cases stimulants are not required. They are called 
for when the pulse is weak, compressible, and rapid, when the face is 
pale and the extremities are cold. The same stimulants are to be em- 
ployed, and in the same way, as in bronchopneumonia. Circulatory and 
respiratory stimulants are usually required in larger quantity at the time 
of and just after the crisis; they are to be used as in bronchopneumonia. 



PLEUROPNEUMONIA 

Under this term are included cases of pneumonia with an excessive 
amount of pleurisy, the two processes uniting to produce a single clinical 
type of disease. 

In nearly all cases of lobar pneumonia there is a certain amount of 
inflammation of the pulmonary pleura, and also in those cases of 'broncho- 
pneumonia which are accompanied by any marked degree of consolida- 
tion. In both of these conditions the pleurisy is usually co-extensive 
with the consolidation. But in certain cases, in both forms of pneumonia, 
the amount of pleurisy is excessive, and this so modifies the symptoms 
and course of the disease as to require for them a separate consideration. 



PLEUROPNEUMONIA 545 

In some it appears that the inflammatory process begins almost simul- 
taneously in the lung and in the pleura ; while in others the pleurisy 
follows the pneumonia. These cases are almost invariably due to the 
pneumococcus, although in some there is a mixed infection. 

In 398 hospital cases of pneumonia there were 27, or 6.8 per cent, 
which could be classed as pleuropneumonia, the diagnosis being con- 
firmed either by autopsy or operation. Of 190 fatal cases, 12.5 per cent 
were cases of pleuropneumonia. Most of these hospital patients were 
under three years of age, and the disease is more frequent at this period 
than in older children. 

Lesions. — Of these 27 cases, 17 were classed as bronchopneumonia 
and 10 as lobar pneumonia. The left lung was more frequently affected 
than the right in the proportion of three to two. In most of the cases 
the pleura covering the entire lung was involved, even though the pneu- 
monia affected but a single lobe, or only a part of a lobe. In nearly 
half the cases both lungs were involved, but one to a very much less 
extent than the other. In a small number of cases the pleurisy was 
limited to the posterior surface of the lung. 

In pleuropneumonia both the visceral and the parietal pleura are 
coated with a layer of yellowish-green fibrin, in thick, shaggy masses, 
causing adhesions of the lung to the chest wall, the diaphragm, and the 
pericardium (Plate IX). The exudation varies between one-eighth 
and one-half of an inch in thickness. Tt can often be stripped from the 
lung or scraped from the chest wall by the handful. In its meshes small 
pockets may form, which contain only a few drops, or sometimes a dram, 
of pus, or less frequently, serum. This is the condition in which the lung 
is usually found when death has occurred at the height of the disease. If 
the process has lasted longer, larger collections of pus may be present. 
The lung itself shows the usual changes of pneumonia, and if there has 
been any considerable accumulation of fluid, there are in addition the 
evidences of compression. The disproportion between the changes in the 
pleura and those in the lung may be striking. Frequently the pulmonary 
lesions are relatively insignificant. 

With pleuropneumonia of the left side, the pericardium is frequently 
involved. The lesions closely resemble those of the pleura. Meningitis 
and peritonitis are by no means rare, and in most of the fatal cases a 
general pneumococcus septicemia is present. The organisms may be 
found in the blood in great numbers during life or post mortem. 

An inflammation of the intensity described is very often fatal in the 
acute stage, if the patient is a child under two years old. Occasionally 
at this age, and very frequently in older children, we see the later stages 
of the process. The most frequent course is for more and more pus to 
be poured out from the inflamed pleura until the chest is filled, the cast! 



546 DISEASES OF THE RESPIRATORY SYSTEM 

becoming thus one of empyema. Sometimes the fluid is serous instead 
of purulent, but this is very rare in infancy. In other circumstances 
the exudation is partly absorbed, but the greater part becomes organized 
so as to form a thick jacket of fibrous tissue which binds the lobe or lung 
to the chest wall and interferes seriously with its subsequent full expan- 
sion. Chronic interstitial pneumonia may follow. 

Symptoms, — There is little which distinguishes a case of pleuropneu- 
monia except the severity of all the constitutional symptoms; the tem- 
perature is often higher, the prostration greater, and the patient in every 
way impresses one as being more seriously ill than with ordinary pneu- 
monia. Sometimes the thoracic pain is more severe and more constant 
than is usual in pneumonia. 

In the early stage pleuritic friction sounds are unusually promi- 
nent ; after two or three days the signs of consolidation come out clearly 
in most cases, but still accompanied by loud friction sounds. After the 
fibrinous exudation is very abundant, the signs are often obscure and 
confusing, and there may be at no time well-defined signs of consolida- 
tion. There is usually a mingling of the signs of consolidation with those 
of effusion. There is marked dulness, and sometimes flatness. The 
vocal fremitus is apt to be diminished, and it may be absent. Bronchial 
voice and breathing are heard, but they are not distinct as in consolida- 
tion; they are, however, feeble and distant, as over fluid. There are 
usually coarse, moist rales but these may be absent. The signs may be 
found over one entire lung, or they may be limited to the posterior region, 
and even to a single lobe. They resemble those present over fluid, with 
one exception — viz., the heart is not displaced. If an exploratory punc- 
ture is made, nothing is found ; occasionally the exploring needle happens 
to strike one of the small pockets of pus in the meshes of the fibrin, and 
a few drops of pus are withdrawn. If an incision is made under the 
supposition that the case is one of empyema, no more pus may be found, 
the surgeon coming upon the fibrinous masses as soon as the chest is 
opened. There is scarcely any condition in the chest giving signs more 
puzzling than those just enumerated. They are, however, easily explained 
by the pathological condition. 

Prognosis. — The prognosis in pleuropneumonia is much worse than 
in simple pneumonia. In infants the outlook is very bad, the majority of 
the cases being fatal during the acute stage. Very young children may 
be overwhelmed with the extent and the intensity of the inflammation, 
and die in four or five days. In children over two years old the most 
frequent result is for the case to go on to empyema, which with proper 
treatment usually terminates in recovery. Where there is organization of 
the fibrin with the production of extensive adhesions, the ultimate result 
often is not so favorable as when empyema develops. Convalescence is 



PLATE IX 



§5= 




01 .- 



~ 5 



- 
_ — . 

/ - = 



x - 

- -a 







HYPOSTATIC PNEUMONIA 547 

usually slow, and the patients are liable to exacerbations of pleurisy; 
they may suffer for years from the partial crippling of one lung. 

Treatment. — Cases of pleuropneumonia are to be managed like the 
ordinary cases of pneumonia of the severe type. In some, the excessive 
pain may call for more active counter-irritation and a freer use of opium 
than in other forms of pneumonia, and the greater prostration may re- 
quire that stimulants be given earlier and in larger quantities. 



HYPOSTATIC PNEUMONIA 

This can not often be recognized clinically, but it is very frequently 
seen upon the post-mortem table. It represents an inflammatory process 
of a low grade and is seen to some degree in almost every case where an 
infant has died of chronic disease. It is particularly frequent in those 
who have died of marasmus. It invariably occupies a strip along the 
posterior border of both lungs, and usually of both the upper and 
lower lobes. This is from one to two inches wide, of a uniform dark 
red color, and is sharply outlined. The pleura is not involved, and the 
remainder of the lung may be normal, congested, or slightly emphysem- 
atous. On section, it is seen that the pneumonic area is quite superficial, 
rarely involving the lung to a greater depth than half an inch. Under 
the microscope there is found a distention of the small blood-vessels in 
the affected area, and the air vesicles are filled with many red blood-cells, 
epithelial cells, and a few leucocytes. Between the areas of consolidation 
are groups of air vesicles which are normal, congested, or collapsed. It is 
a lobular rather than a bronchopneumonia. The lesions in this form 
of pneumonia are probably the result of venous stasis, owing to the child's 
recumbent position. 

At autopsy the condition may be confounded with atelectasis. Little 
significance is to be attached to the finding of hypostatic pneumonia at 
autopsy, and it alone should never be regarded as a sufficient cause of 
death, although it is perhaps the only lesion present. During life it 
may give rise to fine moist rales, which are heard along the spine, 
usually upon both sides; but there is seldom either dulness or bronchial 
breathing. The treatment is that of the primary disease. 



CHRONIC BRONCHOPNEUMONIA— CHRONIC INTERSTITIAL 
PNEUMONIA— BRONCHIECTASIS 

Chronic bronchopneumonia is an inflammation of the connect ive- 
tissue framework of the lung, involving the stroma, the alveolar septa, 
the walls of the bronchi, and the pleura. It is usually accompanied by 



548 DISEASES OF THE RESPIRATORY SYSTEM 

cylindrical dilatation of the bronchi — bronchiectasis. Chronic pneu- 
monia may occur in the well nourished and apparently robust but is more 
common in the delicate. While seen ai all ages its beginning is usually 
before the fifth year. 

Etiology. — In children, as in adults, this process is most frequently 
associated with pulmonary tuberculosis; but in early life it is not an in- 
frequent condition apart from tuberculosis. The non-tuberculous cases, 
as a rule, are preceded by an attack of acute bronchopneumonia, some- 
times by several such attacks, separated by longer or shorter intervals. 
Foreign bodies may cause localized interstitial pneumonia of great sever- 
ity. The organisms associated with chronic pneumonia may be the 
pneumocoecus or the staphylococcus, but more frequently we believe it 
is the influenza bacillus either alone or in combination. It is hard to 
say why in one case complete resolution takes place in a diseased lung 
and in another there follows a chronic progressive lesion. It is probably 
dependent upon a balance between the individual resistance and the sever- 
ity of the infecting organism. 

Lesions. — The part of the lung affected may be an entire lobe, but 
usually it is a portion of one lobe, or there are areas in more than one 
lobe. There are dense connective-tissue adhesions binding the diseased 
part to the chest wall, to the diaphragm and to the pericardium, often 
so firmly that the lung is torn on removal. The affected lung is smaller 
than in health; it is hard, tough, and fibrous. Surrounding the fibrous 
portions are emphysematous areas. On section, the process is seen to 
be somewhat irregularly distributed through the lung, the lesion being 
usually most marked in the vicinity of the smaller bronchi, and some- 
times seen only there, the intervening lung being nearly normal (Plate 
X). In some portions, where the process is most advanced, almost 
all trace of lung tissue may have disappeared, the part resembling a solid 
fibrous tumor, through which run the bronchial tubes, usually much 
dilated. In places this dilatation may be sufficient to form cavities of 
considerable size. The bronchial glands are often enlarged to the size 
of a hazelnut, and they may be tuberculous. 

Upon examination with the microscope, the pleura is found greatly 
thickened, with bands of new fibrous tissue passing from it into the lung. 
The walls of the small bronchi are in most places thicker than normal, 
but elsewhere they have undergone cylindrical dilatation, and are rilled 
with pus. The walls of the alveoli show a marked proliferation of the 
connective-tissue elements, and the alveoli are filled with organized in- 
flammatory products, so that they are nearly or quite obliterated. The 
stroma is much increased in amount throughout the affected lung. 

Symptoms. — In most cases there is a history of repeated attacks of 
acute bronchopneumonia, from which the child made a slow con vales- 



PLATE X 




Chronic Bronchopneumonia 
In the greater part of the specimen the disease is limited to the vicinity of the small 
bronchi, AAA, each of which is surrounded by a zone of new connective tissue, the result 
of the inflammatory process, the intervening lung tissue, B B. being normal. In the 
lower left-hand portion, the disease is more diffuse- the air vesicles, C, between the areas 
of new connective tissue are creatly compressed, and in some places entirely obliterated. 

(After Delafield.) 



1 



CHRONIC BRONCHOPNEUMONIA 549 

cence, remaining pale, anemic, and sometimes wasted for several months. 
Improvement then took place in the general symptoms, the appetite and 
strength returned, and in many cases the lost weight was nearly or quite 
regained. However, neither the pulmonary symptoms nor the physical 
s^ns entirely disappeared. There remained a 'dry, hard cough, which at 
tunes was severe. Pains in the chest were occasionally complained of, 
and perhaps shortness of breath on exertion was noticed. 

Examination shows a persistence of the dulness on percussion, with 
a rude or bronchovesicular respiratory murmur of very feeble intensity. 
Little change may take place in these signs for months; then an acute 
attack of bronchitis or bronchopneumonia may occur. If the latter, the 
same lung is affected, and a fresh consolidation is added to the previous 
disease. This attack may not be very severe, but it drags on for several 
weeks, with slight fever and little or no change in the physical signs. 
Partial resolution may then take place, but the lung is left much mere 
seriously crippled than before. Often there is a history of several such 
attacks, each one leaving the lung a little worse than it found it. 

The characteristic physical signs of chronic bronchopneumonia are 
not usually present until the process has continued for many months. 
They may be found over part of a lobe, or over an entire lobe, or even the 
greater part of one lung. On inspection, there may be seen, in a well- 
marked case, retraction of the chest, which is especially noticeable when 
the disease is situated at the apex of the lung. The vocal fremitus is 
usually increased, but it may not be abnormal. There is marked dulness, 
often flatness, over the affected area, with exaggerated resonance over 
the rest of the lung. The area of flatness shades off gradually. The most 
striking thing on auscultation is the very feeble respiratory murmur; in 
many cases the lung is almost silent. More rarely there is marked bron- 
chial voice and breathing. Hales and friction sounds are usually absent 
except during an acute exacerbation of the symptoms, when they may 
be heard as in any attack of bronchopneumonia. In recent cases there 
is no displacement of the heart; in those of long standing it may be 
drawn far to the affected side by contraction of the adhesions. There 
may be clubbing of the fingers in cases of long standing. 

When these lesions are once present complete recovery is impossible, 
and there is always a tendency for them to increase rapidly or slowly, 
according to the child's vigor of constitution, bis surroundings, and the 
frequency with which exacerbations occur. If the process is extensive 
the patient often succumbs to some intercurrent disease or t«» an acute 
attack of pneumonia; if limited in area, the process may he arrested and 
the patient recover, always, however, to be more or less embarrassed 
because of the crippling of a part of one Lung. N-i a small nun. her of 
these children ultimately die of tuberculosis, and in such cases it i> al- 



550 DISEASES OF THE RESPIRATORY SYSTEM 

ways a difficult matter to decide whether tuberculosis was present from 
the beginning, or whether it was due to subsequent infection. 

The cases in which bronchiectasis is the most important condition 
are not common. The only characteristic additional symptom is a 
copious mucopurulent expectoration, which is usually very fetid. It 
may amount to several ounces a day, and is expelled after paroxysms of 
coughing, which usually occur in the morning. This may continue for 
months, or even years, and yet these patients are generally without fever, 
seldom lose weight, and may have the appearance of being in very good 
health. It is rare that the physical signs of a cavity are present. 

Prognosis. — This depends on the extent of the disease, the patient's 
age and constitution, and on our ability to prevent by treatment, climatic 
and otherwise, the occurrence of acute exacerbations. Under the most 
favorable conditions, a few patients may recover completely so far as 
symptoms are concerned; but the majority remain at best delicate during 
childhood, or even throughout life. 

Diagnosis. — The most important thing is to distinguish between the 
simple and the tuberculous cases, and this, by symptoms and physical 
signs, is in the majority impossible. If the family history is good, if 
the patient lives in the country, if his symptoms begin with a well- 
defined acute attack of pneumonia, if the seat of disease is the base pos- 
teriorly, and if the examination of the sputum is negative for tubercle 
bacilli the process is probably simple. If the family history is doubtful 
or is positively tuberculous, if the patient lives in the city, and especially 
if he is an inmate of an institution or if his home is in the tenements, 
if the initial symptoms are indefinite, if the disease is situated anteriorly, 
the process is probably tuberculous. The cutaneous tuberculin test aids 
much in diagnosis. With a negative reaction tuberculosis can be ex- 
cluded almost with certainty ; but a positive reaction does not prove that 
the pulmonary process is tuberculous, although it is strongly sugges- 
tive. The discovery of tubercle bacilli in the sputum is, of course, con- 
clusive. 

Foreign bodies in the lung may give symptoms of chronic broncho- 
pneumonia; metallic and many solid substances may be detected by the 
X-ray. 

Treatment. — Nothing has any essential influence upon the disease 
except change of climate. This should be the same as for tuberculous 
cases. The treatment of the patient has for its object the maintenance 
of the general nutrition at its highest point, by careful feeding, judicious 
exercise, and by most of the measures enumerated in the chapter on Mal- 
nutrition. Cod-liver oil may often be given with advantage especially 
during the winter. The cough may be treated as in cases oi chronic 
bronchitis. 



ABSCESS OF THE LUNG 551 

Cases of bronchiectasis may obtain considerable relief from inhala- 
tions of creosote. Operation is not to be recommended. 



ABSCESS OF THE LUNG 

Multiple small abscesses are not uncommon as a termination of acute 
bronchopneumonia, in which connection they have already been consid- 
ered. Larger non-tuberculous abscesses of the lung are rare, very obscure 
in their symptoms, and apt to be mistaken for localized empyema, some- 
times for interstitial pneumonia with bronchiectasis. Four such cases 
have come under our observation. One Avas discovered at autopsy, the 
other three Avere recognized during life and successfully treated by opera- 
tion. Other examples in young children have been reported by Huber 
and by Hedges. The cause of these single abscesses is usually a previous 
attack of acute primary pneumonia, less frequently an inflammation ex- 
cited by a foreign body in the lung. 

An abscess due to a foreign body is usually accompanied by wasting, 
and a widely fluctuating temperature of a hectic type- — symptoms sug- 
gestive of a rapidly advancing tuberculous process.- If the abscess fol- 
lows an ordinary pneumonia the course is generally less intense. The 
constitutional symptoms differ little from those of empyema. There is 
an irregular type of fever, sometimes quite high, but more often only 
from 99° to 101° or 102° F., a moderate cough, not much wasting, and 
generally not very marked prostration. A leucocytosis of 30,000 to 
50,000 is usually present. The physical signs are somewhat confusing 
and are a combination of those present in effusion and consolidation. 
There is an area of flatness shading off into dulness. The vocal fremitus 
may be- increased or it may be diminished. The respiratory murmur is 
very feeble or absent over the abscess, often it is bronchovesicular in char- 
acter. Friction sounds and rales are usually present. The head is 
slightly or not at all displaced. If an exploratory needle is introduced; 
pus may not be found even by repeated punctures; or it may he obtained 
at one time and not at another, although introduced in the same 
intercostal space, the difference in result being due to the direction in 
which the needle is passed into the lung. When pus is found. I he 
diagnosis of a localized empyema is generally regarded as established, 
and it is not until the chest is opened that the mistake is discovered. 
The operator then comes upon the lung, which may or may not be 
adherent. If the abscess follows an acute pneumonia the \m< may 
show a pure culture of the pneumococcus. If it is due to a foreign body, 
there is invariably a mixed infection, and the pus is apl t<> l>" fetid. 

When not treated surgically, abscess of the lung may rupture into 



552 DISEASES OF THE RESPIRATORY SYSTEM 

the pleural cavity, producing a secondary empyema, or spontaneous 
evacuation may take place through a bronchus and recovery follow. 
When the cause is a foreign body, rapid recovery often follows its ex- 
pulsion by coughing. If the diagnosis is made and proper surgical 
treatment is instituted, recovery occurs in probably the majority of 
cases. 

The general plan of treatment should be the same as in empyema. 
In a small proportion of cases aspiration may suffice for a cure. How- 
ever, incision is usually necessary. If the pleura is not adherent, adhe- 
sions should be excited by packing the thoracic wound with gauze, and 
after a few days a second operation may be clone. The lung should be 
opened with a blunt instrument, following the line of the exploring 
needle, and a drainage-tube inserted as in empyema, the subsequent 
treatment being the same as for that disease. 



GANGRENE OF THE LUNG 

Pulmonary gangrene is rare in children, although probably more com- 
mon than in adults. It is most frequently associated with pneumonia. 
It is usually circumscribed, and seldom diagnosticated during life. 

Etiology. — All but one of our cases have been in children under 
three years old, the youngest an infant of four months. Gangrene occurs 
for the most part in children who are ill-conditioned, feeble, or cachectic, 
and often follows one of the infectious diseases, particularly measles. 
Of twelve cases which have come under our personal observation, eight 
complicated acute bronchopneumonia. Pulmonary gangrene has been 
present in about three per cent of our autopsies upon cases of pneu- 
monia. The immediate cause of the necrotic process is interference 
with the circulation in a part of the lung, which is usually due to throm- 
bosis or embolism of some of the branches of the pulmonary artery. To 
this there is added the entrance of putrefactive bacteria. In some cases 
pulmonary gangrene may begin as a septic thrombosis, this infection 
originating in some process in a distant part of the body. 

Lesions. — The lower lobes are more frequently affected than the 
upper, and the surface of the lung rather than the central portions. 

Two forms of gangrene may be seen : the diffuse form, which affects 
a whole lobe, or even a whole lung; and the circumscribed form, which 
occurs in a number of small scattered areas. The latter is the variety 
usually seen in children. In the diffuse form the lung is of a dirty- 
green or brown color, moist, and emits a gangrenous odor. In the 
circumscribed form, when occurring in pneumonia, the parts affected arc 
of a gray or green color, usually wedge-shaped, with the base at the 



ACQUIRED ATELECTASIS— PULMONARY COLLAPSE 553 

surface of the lung. In the early stage they are not softened, and have 
no gangrenous odor; later, both these conditions may be present, and 
masses of necrotic lung tissue may be found in a cavity with ragged walls, 
partly filled with fetid pus. Careful dissection will reveal, in many 
cases, the presence of thrombi in the vessels leading to the gangrenous 
parts. 

Symptoms. — There are but two distinctive symptoms of pulmonary 
gangrene: the fetid odor of the breath, and the expectoration of masses 
of necrotic lung tissue. In the cases associated with acute pneumonia, 
which include the majority of those seen, death nearly always takes 
place before there is any separation of the sloughs, and even before 
very active decomposition in the necrotic areas has occurred. Both the 
peculiar symptoms are therefore wanting, and the diagnosis is made 
only at the autopsy. This has been true of nearly all the cases which 
have come under our observation. But these patients, with two ex- 
ceptions, were infants. In older children, particularly in cases secondary 
to the entrance of a foreign body, the characteristic symptoms are more 
frequently seen, and there may be a third symptom — hemorrhage. This 
is present in about one-fourth of the cases (Rilliet and Barthez), and 
may be fatal. The general symptoms associated with gangrene are those 
of profound asthenia, resembling the typhoid condition. 

From what has been said, it will be evident that the diagnosis is very 
difficult. If the characteristic odor of the breath is present, conditions 
in the mouth from which it might arise must be excluded. Cavity forma- 
tion in tuberculosis may also be a cause of a very foul breath. The 
cutaneous tuberculin test will aid greatly in the diagnosis. The physical 
signs differ in no respect from those of ordinary cases of pneumonia. 
The termination is almost always in death. This is due not only to the 
condition itself, but to the circumstances in which it is seen. 

Treatment. — The general treatment should be supporting and stimu- 
lating, as in all severe cases of pneumonia. For the local process but 
little can be done, except the inhalation of antiseptics, of which creosote 
and turpentine are undoubtedly the best. 



ACQUIRED ATELECTASIS— PULMONARY COLLAPSE 

These terms are applied to a state of the lung resembling I he fetal 
condition, but occurring in a lung which has once been expanded. It 
may be due to compression or to obstruction. 

Collapse from Compression. — The principal cause of tliis form is 
pleuritic effusion. It may also be produced by pneumothorax, enlarge- 
ment of the heart, pericardial ('(fusion, deformities of the ehesl from 



554 DISEASES OF THE RESPIRATORY SYSTEM 

rickets or Pott's disease, and tumors of the mediastinum or the thoracic 
wall. In these conditions, on account of the external pressure, the air 
vesicles are not filled, although the bronchi are pervious. After collapse 
has existed for a considerable time, changes may take place in the lung 
which render expansion difficult or impossible. Unless, however, there 
are pleuritic adhesions, expansion often takes place readily after many 
weeks or even months. The symptoms and signs are those of the 
original disease. 

Treatment is available chiefly in that form which follows pleuritic 
effusion, and will be considered in the chapter on Empyema. 

Collapse from Obstruction. — This is due to two factors: blocking of 
either the large or small bronchial tubes, and feeble inspiratory force. 
The importance of collapse from obstruction in the acute diseases of 
the lung in infancy has undoubtedly been exaggerated. Whenever a large 
or small bronchus is completely obstructed by a foreign body, the portion 
of the lung to which the bronchus is distributed gradually becomes 
collapsed. If it is one of the primary bronchi which is occluded, 
a whole lung may be collapsed; if one of the lobar divisions, an entire 
lobe; if one of the smaller divisions, only a small area. The collapse 
does not take place immediately, but the contents of the air vesicles are 
gradually absorbed. The collapsed portion is slightly depressed below 
the surface of the lung. It is of a dark-red color, very vascular, and to 
the naked eye resembles a pneumonic area, which it may subsequently 
become. 

Many writers explain the development of bronchopneumonia from 
bronchitis of the smaller tubes, through the intervention of pulmonary 
collapse, assuming that the obstruction of the small bronchi, from swell- 
ing of their walls and the accumulation of secretion, produces the same 
result as the plugging of a bronchus by a foreign body. In our own 
autopsies we have found little support for this theory. In acute bron- 
chitis of the smaller tubes the lumen is narrowed, but seldom enough 
to prevent the entrance of air. The result is usually emphysema, not 
atelectasis. Such, at least, has been the condition we have most fre- 
quently found in autopsies in the earliest stage of bronchopneumonia fol- 
lowing bronchitis of the fine tubes. There are very often groups of 
collapsed air vesicles surrounding pneumonic areas, but these are neither 
an essential nor a very important part of the lesion. Collapse of a 
large part of the lung, or even of a lobe, we have never seen, either 
in pertussis or in acute bronchitis. 

There is seen in delicate or rachitic infants a form of collapse 
which comes on very gradually. It is accompanied by bronchitis affect- 
ing the tubes in the dependent part of the lung. It may resemble 
the congenital form of atelectasis. Under the microscope there is almost 



EMPHYSEMA 555 

invariably found; accompanying the collapse, lobular pneumonia and 
bronchitis of the tubes in the affected regions. 

The symptoms of acquired atelectasis are much the same as in the 
persistent congenital form. The respiration is rapid, and there may be 
inspiratory dyspnea with deep recession of the chest walls, especially if 
there is rickets. There is also at times cyanosis of variable intensity. 
The temperature is not elevated, but frequently is subnormal. The phys- 
ical signs are very uncertain. There is usually feeble respiratory murmur 
over the affected areas, occasionally accompanied by moist rales. The 
essential point of difference between these cases and those of congenital 
atelectasis is that in the former the patients are often strong at birth, 
crying and breathing well, giving no signs of anything wrong in the lungs 
until the general nutrition has suffered from some other cause. 

The following is a fairly typical case: A female infant thirteen 
months old had been under observation for several months before death. 
During this period she suffered a great part of the time from mild 
bronchitis. The chest was extremely rachitic. The respiration was 
always accelerated, and on inspiration the lateral recession of the chest 
was at times extreme. There was occasionally seen slight cyanosis, and 
during the last few weeks it was constant. Death occurred quite sud- 
denly. At autopsy there was found very marked vesicular emphysema 
of both lungs in front. Nearly the whole of both lower lobes were in 
a condition of collapse, and of a uniform grayish-purple color. The pos- 
terior portion of the upper lobes was similarly affected, but to a less 
degree. With moderate force all of the collapsed areas could be com- 
pletely inflated. Bronchitis was present, but the pleura was normal. 

The treatment of these cases is the same as that outlined in the 
chapter upon Congenital Atelectasis. 



EMPHYSEMA 

Pulmonary emphysema consists primarily in overdistention of the air 
vesicles. It may result in their rupture and the escape of air into the 
interlobular connective 1 issue of the lung. In infancy and childhood 
emphysema is usually associated with acute processes. 

Etiology. — Cases of emphysema are divided into two groups which 
are due to quite different causes. In one group it is compensatory, 
and consists in overdistentiou of the air vesicles in certain parts of the 
lungs because the full expansion of other parts is prevented either 

because they are consolidated, as in pneumonia or tuberculosis, 1" d 

down by adhesions from old pleurisy, or subjected to external pressure, 
as from chest deformities due to Pott's disease or rickets. In these 



556 DISEASES OF THE RESPIRATORY SYSTEM 

conditions it is probable that the emphysema is produced during inspira- 
tion. It may also be produced by the artificial inflation of the lungs of 
the newly born. 

In the second group of cases emphysema is produced by obstructive 
expiratory dyspnea or cough. It is seen in all forms of laryngeal stenosis, 
in acute bronchitis and bronchopneumonia, in asthma, pertussis, and 
occasionally it is produced by any condition which requires deep inspira- 
tion and holding the breath. In bronchitis the obstruction may be caused 
by a swelling of the mucous membrane or by. an accumulation of secre- 
tion. In this group of cases air enters the lung, but as it can not readily 
escape, the air vesicles are distended, sometimes to such a degree that 
their resiliency is almost entirely lost. 

Lesions. — The most common form in early life is acute vesicular 
emphysema, which occurs when the force distending the air cells is only 
moderate. In this form there is dilatation of the vesicles with very 
slight structural changes, there being usually rupture of a few alveolar 
septa only (Fig. 49). Although the dilatation may be quite marked, 
the emphysema is not permanent. The parts most affected are the 
upper lobes, particularly the anterior borders. In appearance the emphy- 
sematous lung is pale, sometimes almost white. The affected areas are 
prominent, and do not collapse upon opening the chest. With a lens, or 
even with the naked eye, the individual air vesicles can often be dis- 
tinguished as minute pearly bodies, at times resembling miliary tubercles. 
When the disease is secondary to acute bronchitis or laryngeal stenosis 
it may affect nearly the whole of both lungs. 

With a greater distending force rupture of many of the air vesicles 
results, and this may give rise to interstitial or interlobular emphysema. 
At times blebs are formed, varying in size from a pin's head to a cherry 
or even larger ones. These are usually seen at the anterior border or at 
the root of the lung on its inner surface. Again, the air finds its way be- 
tween the lobules, dissecting them apart in all directions throughout the 
lung. Sometimes a large part of the surface of both lungs is seamed with 
irregular deep crevasses containing air, the largest being an inch or more 
in length and nearly one-fourth of an inch wide. The most severe cases 
occur in pertussis. On two or three occasions we have seen this form 
of emphysema, once to an extreme degree, when children had died from 
diseases unconnected with the respiratory tract, and when no history 
could be obtained which threw any light upon the etiology of the em- 
physema. 

Localized emphysema not infrequently occurs in the subcutaneous 
tissue of the thoracic wall following exploratory puncture of the chest. 
This is seldom extensive and the air usually disappears in a few days by 
absorption without causing any symptoms. Sometimes from a rupture 



EMPHYSEMA 



557 



of an emphysematous vesicle at the hilus of the lung there occurs em- 
physema of the mediastinum which may spread to the tissues of the neck 
and ultimately to almost the entire body. The patient gives the impres- 
sion of having been artificially inflated (Fig. 72). Such widespread 

emphysema is usually as- 

sociated with conditions 
which prove fatal, the em- 
physema adding much to 
the patient's discomfort but 
not increasing the danger of 
the original disease. 

Symptoms. — E m p h y- 
sema occurring in acute 
pulmonary diseases gives 
rise to no peculiar symp- 
toms and to no physical 
signs except exaggerated 
resonance upon percussion. 
This masks dulness from 
consolidation and also that 
from the liver and spleen. 
If the patients recover from 
the original disease, the em- 
physema greatly diminishes 
or disappears completely in 
the course of a few weeks or 
months. Acute interlobular 

emphysema can not be diagnosticated during life, unless, as is sometimes 
the case, general subcutaneous emphysema is seen, which may come on 
quickly, last for several hours or days and then gradually disappear. 

The treatment of emphysema is that of the disease with which it is 
associated. 




Fig. 72. — General Subcutaneous Emphysema, 
Child 14 Months Old. Following perfora- 
tion of a caseous nodule at the root of the 
lung; pulmonary tuberculosis. 



CHAPTER VI 
PLEURISY 



All the common forms of inflammation of the pleura are seen in 
childhood. In the great majority of cases they are secondary <<> disease 
of the lung itself. Serous effusions are much less frequeni than in adults, 
and under three years large ones are rare. Purulent eifusion (empyema) 



558 DISEASES OF THE RESPIRATORY SYSTEM 

is, however, much more often seen than in adult life, and it is the most 
important variety of pleurisy with which the physician has to deal. 

Whether inflammation of the pleura ever occurs as a strictly primary 
disease is still a mooted point. Cases are occasionally observed clinically 
in which both the serous and purulent forms of the disease appear to be 
primary, but these are extremely rare. Acute pleurisy may, however, 
follow inflammation of the lung so rapidly that it is not easy to de- 
termine that the lung was first affected. In infants, extension from the 
lung is almost the sole cause. It occurs both with lobar and broncho- 
pneumonia, existing to some degree in nearly every case in which there 
is consolidation of the lung. Next in frequency to simple pneumonia as 
a cause of pleurisy are the tuberculous processes of the lung. Tuberculous 
pleurisy without tuberculosis of the lungs or the bronchial glands is 
of doubtful occurrence. Acute pleurisy is an occasional complication 
of the infectious diseases, particularly scarlet and typhoid fevers, measles, 
and influenza. In most of these cases also it is secondary to 
disease of the lung. Pleurisy in older children occasionally follows 
cold and exposure, although it is doubtful whether in any case this 
is the only cause. In them also it may occur as a complication of 
rheumatism. 

The most important cause of acute pleurisy being extension from 
pneumonia, it follows that it is most frequent in the cold season, that it 
occurs more often in males than in females, and between the ages of one 
and five years. It may, however, be seen at all ages, and may even occur 
in intra-uterine life. The youngest case in which we have found ex- 
tensive pleuritic adhesions as an evidence of previous inflammation was 
in an infant of three months. In this case firm connective tissue ad- 
hesions were found over the whole of both lungs. 



DRY PLEURISY 

In infants and young children this usually accompanies pneumonia 
or tuberculous processes in the lung. In older children it may be pri- 
mary. 

Lesions. — On account of the frequency with which this occurs in 
pneumonia we have an opportunity of observing it in all stages. In the 
mildest varieties it affects only the pulmonary pleura, and occurs over the 
pneumonic areas. The pleura is injected, has lost its luster, and appears 
dull or roughened. This is due to an exudation of fibrin upon its sur- 
face. If the process continues, more fibrin is poured out, and there are 
in addition swelling and a proliferation of the connective-tissue cells, and 
an exudation of leucocytes from the blood-vessels. The pleura is then 



DRY PLEURISY 559 

coated with a layer of fibrin of variable thickness, in which are entangled 
pus cells and new connective-tissue cells. The layer of fibrin varies from 
the thickness of tissue paper to that of an ordinary book cover. In re- 
cent cases it may easily be stripped off, while in older ones it becomes 
organized and is firmly adherent. The color of the exudate varies with 
the number of pus cells. It is gray, grayish-yellow, or yellowish-green, 
according as these cells are few or numerous. As a rule, dry pleurisy 
is localized, but the two opposing surfaces are affected. Part of the 
exudate is usually absorbed, but it is doubtful if complete recovery oc- 
curs, there being left behind some adhesions between the visceral and 
parietal layers. 

In the dry form of tuberculous pleurisy there may be only an ex- 
udation of fibrin, or the pleura may be covered with gray tubercles and 
yellow tuberculous nodules. These are not only seen upon the surface 
of the pleura, but develop in the exudation. In this form, which is 
usually chronic, great thickening of the pleura may take place. Both 
the serous and purulent effusions occurring in conjunction with tuber- 
culosis are likely to be sacculated because of the previous existence of 
adhesions. 

After nearly every case of dry pleurisy there probably remains some 
slight thickening of the pleura. In certain cases there follows a chronic 
inflammation of the pleura with the production of new connective tissue, 
which results in thickening and adhesions which may be so extensive as 
to entirely obliterate the pleural cavity. Either one or both sides may 
be affected. It is usually accompanied by external pericarditis. This 
form is rare in childhood. 

Symptoms. — As an independent clinical disease, acute dry pleurisy 
has no existence in infancy or early childhood. The cases which are occa- 
sionally so diagnosticated have in our experience invariably proved to be 
bronchopneumonia. In older children dry pleurisy may occur under the 
same conditions as in adults. 

The symptoms are sharp, localized pain, increased by full inspiration, 
sometimes tenderness upon pressure, and a short, teasing cough. The 
pain is not always felt upon the affected side, and it may be referred <«> 
the abdomen. Upon physical examination, dry pleurisy is recognized by 
the presence of a pleuritic friction sound. This is usually of ;i dry 
rubbing character, generally localized, and beard both on inspiration 
and expiration. It is quite superficial, and not changed by coughing. 
This form of pleurisy, as a rule, runs a course of ;i few days <>r ;i week 
without constitutional symptoms. When dry pleurisy occurs ;i- ;i com 
plication cf pneumonia it is recognized by the signs jusl mentioned ; bui 
it usually causes no new symptoms except pain. 

Treatment. — The treatment consists in counter-irritation l>v mua- 



560 DISEASES OP THE RESPIRATORY SYSTEM 

tarcl or iodin, according to the severity of the inflammation, and in the 
use of opium. Severe pain can sometimes be relieved by firmly encircling 
the chest with a broad band of adhesive plaster. 



PLEURISY WITH SEROUS EFFUSION 

This form of pleurisy is not common in young children, and in 
infants except with acute pneumonia it is rare. In those somewhat 
older it is usually tuberculous in origin in which case it frequently acts 
like a primary disease. It occurs as a complication of pneumonia 
and may be seen in nephritis, acute rheumatism, scarlet fever, or any 
of the other acute infectious diseases. Bacteria are occasionally present 
in the exudation, even in cases which do not become purulent, but their 
number is usually small. The tubercle bacillus, the streptococcus and 
the pneumococcus are the forms most often seen. 

Lesions. — The early changes are much the same as in dry pleurisy, 
but in addition serum is poured out from the blood-vessels, in some 
cases almost from the beginning of the inflammation. This may be 
small in amount, or it may fill the pleural cavity. The lesions are 
similar to those seen in adults, except that in children there is apt 
to be more fibrin. The process usually terminates in absorption of the 
serum, but, as in dry pleurisy, more or less extensive adhesions are left 
behind from the fibrinous exudation. In other cases there is at first a 
clear serum, often containing pneumococci, then it becomes somewhat 
turbid, and finally purulent. This is especially common in infants. 

Symptoms. — The very small serous effusions which occur so fre- 
quently as a complication of pneumonia rarely cause new symptoms or 
a change in the physical signs. In the present connection only those 
cases will be discussed in which the amount of effusion is considerable. 
This form of pleurisy sometimes follows a well-defined attack of pneu- 
monia. Other cases come on with acute febrile symptoms somewhat 
resembling those of pneumonia, but with all the symptoms less severe, 
except the pain. After an illness of only two or three days the chest 
may be found full of fluid. In a third group the disease comes on in- 
sidiously, with little or no fever, and often with no distinct pulmonary 
symptoms except shortness of breath. There is general weakness, some- 
times loss of flesh, anemia, and moderate prostration; but usually the 
patients are not sick enough to go to bed. The symptoms of pleurisy 
with effusion vary greatly. When it occurs as a complication of some 
acute infectious disease, it is often latent, and the diagnosis is to be 
made only by the physical examination of the chest. 

In cases in which the fluid does not become purulent, the usual course 



PLEURISY WITH SEROUS EFFUSION 561 

of the disease is for the fluid to disappear gradually by absorption, the 
case going on to spontaneous recovery. Serious symptoms resulting 
from pressure upon the heart and lungs are not common, but may occur 
when the fluid accumulates rapidly; hence they are most likely to be 
seen early in the attack. There may be great dyspnea, sometimes 
orthopnea, cyanosis, weak pulse, and even attacks of syncope. Death 
may occur with these symptoms. In certain cases there is seen no 
tendency to spontaneous absorption, and the exudation may remain sta- 
tionary for months. There may then be fever, usually slight but some- 
times quite regular, with a decline in the general health, pallor and 
anemia, which may strongly suggest the existence of pus, although this 
is not present. Others are regarded as cases of tuberculosis. 

Physical Signs. — The signs in the chest are essentially the same 
whether the fluid is serous or purulent. On inspection, there is dimin- 
ished movement of the affected side, sometimes bulging of the intercostal 
spaces, and if the effusion is large, an increase in the measurement of 
the affected side of the chest. The apex beat of the heart will usually 
be considerably displaced if the effusion is upon the left side. It may 
be found at the epigastrium, at the right border of the sternum, or even 
in the right mammary line. In disease of the right side the displacement 
is less, and occurs only with a large effusion. It may then be found in 
or near the left axillary line. On palpation, the vocal fremitus is usually 
diminished or absent, but it may be but little changed. Percussion gives 
marked dulness or flatness. In a large effusion this is over the entire 
lung. There is also a sensation of increased resistance appreciable by the 
percussing finger. With a smaller effusion there is usually flatness over 
the lower part of the chest and dulness or tympanitic resonance above ; 
sometimes dulness is found behind and tympanitic resonance at the apex 
in front. The line of flatness may change with the position of the patient. 
(Jrocco's sign is found in the majority of cases. This is a small tri- 
angular area of dulness posteriorly, with its base to the spine, on the side 
opposite to the effusion. The signs on auscultation are variable, and 
probably lead to more frequent mistakes in diagnosis than in any other 
pulmonary affection. Bronchial breathing and bronchial voice over the 
fluid are common in children. Absence of both voice ami breathing is 
sometimes met with, but it is exceptional. The bronchial breathing 
over fluid usually differs from that over consolidation, in that it is feebler 
and distant; in some cases, however, it is indistinguishable from thai 
heard over consolidation. Friction sounds may he heard above the level 
of the fluid, or when the fluid is subsiding, and there may he bronchial 
rales. 

Diagnosis. — The most reliable signs for diagnosis are displacemenl 
of the heart, flatness on percussion, absence of rales and friction sounds, 



562 DISEASES OF THE RESPIRATORY SYSTEM 

and (usually distant) bronchial breathing. In an infant, flatness should 
always lead one to suspect fluid. If there is flatness over one entire 
lung, the existence of fluid is almost certain. Between serous and 
purulent effusions a positive diagnosis is possible only by the use of the 
exploring needle. This should be employed in every case, as it is im- 
portant to know early whether or not we have a purulent effusion to deal 
with. The amount of fluid in serous pleurisy is generally less than in 
the purulent variety. 

Pleurisy is further to be differentiated from pneumonia, and from 
tuberculosis. From pneumonia, the acute cases are distinguished by the 
lower temperature, the less severe prostration, lower leucocyte count and 
the fact that all the general symptoms are milder ; but especially by the 
physical signs. The differential diagnosis by the physical signs between 
effusion and the various forms of consolidation is considered under the 
head of Empyema. 

Prognosis. — In the acute cases complicating pneumonia, a serous 
pleurisy is very apt to become purulent. Other forms of pleurisy with 
effusion, as a rule, terminate in recovery by absorption. In cases com- 
ing on without definite cause there should always exist a suspicion of 
tuberculosis, and hence every patient should be closely watched for the 
development of the other signs of that disease. 

Treatment. — In the great majority of cases, only symptomatic treat- 
ment is required during the acute period. The patient should be kept 
in bed, and pain relieved by opium, counter-irritation, or dry cups. After 
the fever has ceased the patient may be allowed to sit up, but all exer- 
tion should be carefully avoided if the effusion is large. Sudden death 
has occurred when this rule has been violated. The patient should in 
suitable weather be kept in the open air as much as possible. In the 
course of a few weeks the effusion usually subsides under simple tonic 
treatment. Absorption may sometimes be hastened by counter-irritation 
and diuretics; but convalescence is apt to be slow, and it may be several 
months before the health is entirely restored. 

The removal of the fluid by operation is indicated in the acute form 
when it is accumulating so rapidly as to endanger life from the pressure 
upon the heart and lungs; also when there is no tendency to absorption 
after from two to three weeks of constitutional treatment. In such cases 
nothing is to be gained by waiting, and harm may be done to the lung 
by the delay. The usual method is by aspiration. In the acute stage 
enough should be removed to relieve the patient's symptoms, aspiration 
being repeated if necessary in twelve or twenty-four hours. In infants, 
particularly, there is great danger of wounding the lung when aspiration 
is repeated several times. This usually results in the production of 
pneumothorax which may mask the re-accumulation of the fluid. In 



EMPYEMA 563 

the subacute stage the removal of a portion of the fluid may be all that 
is required, spontaneous absorption of the remainder often taking place 
quite promptly. 

EMPYEMA 

Fully nine-tenths of the cases of empyema in children under five years 
either occur with or follow pneumonia, being usually the sequel of the 
form described as pleuropneumonia. In some of these cases, however, 
the pleurisy masks the pneumonia, so that the former appears to be the 
primary disease. Tuberculosis is a rare cause in early childhood, but 
becomes more frequent after the seventh year. Empyema may com- 
plicate scarlet fever, measles, or any of the other acute infectious dis- 
eases. It is met with in pyemia from all causes. It may occur in the 
newly born as the result of infection through the umbilical wound or 
the skin. It is seen with suppurative inflammations of the joints and 
with osteomyelitis. It may complicate suppurative processes in the ab- 
domen, such as appendicitis or purulent peritonitis. Among the local 
causes may be mentioned traumatism, necrosis of a rib, and the rupture 
into the pleural cavity of abscesses originating in the mediastinum, in 
the thoracic wall, or below the diaphragm. 

Since empyema is generally secondary to pneumonia, its causes are 
mainly those of that disease. Of 180 cases observed at the Babies' Hos- 
pital in which the nature of the organism was determined it was as fol- 
lows, 83 per cent of these patients being under two years of age : 

Pneumococcus 115 

Streptococcus 26 

Staphylococcus 14 

B. Influenzae 1 

B. Tuberculosis 1 

Mixed infections 23 

Two-thirds of the mixed infections showed the pneumococcus. The 
predominance of the male sex is even more striking than in pneumonia. 
Of 204 consecutive cases in the same institution the proportion of males 
was 68.6 per cent. 

Lesions. — Empyema is an inflammation with the production of 
serum, fibrin, and pus. In most of the cases — and the younger the 
child the more frequent its occurrence — it succeeds pleuropneumonia. 
There is first an exudation of fibrin with an excess of pus cells. As the 
process continues, more and more pu^ is poured out. witb serum, At 
first the fluid collects in small pockets formed by the slighl adhesions. 
As it accumulates these arc broken down, and the pleural cavity may be 
filled with pus. If the original inflammation involved but a portion of 



64.0 


per cent. 


14 4 


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u 


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a 


12.8 


tt 



564 



DISEASES OF THE RESPIRATORY SYSTEM 



the pleura the empyema may be sacculated. This is often seen even in 
infants. Much has been written regarding inter-lobar empyema. This 
we have never seen either at autopsy or operation and we believe it to 
be a very rare condition in children. Localized empyema is, however, 
seen very often. It is usually posterior and over one lower lobe, but 
may be in any part of the chest. In very rare cases there may be 
several sacs containing pus, separated by septa. Such a condition we have 

never seen in empyema 
following pneumonia. 
The cases just described 
are those in which, in in- 
fants and young children, 
the pneumococccus is 
regularly found. The 
amount of fibrin is large, 
covers both surfaces of 
the pleura, and many 
large masses float in the 
fluid. The pus is usually 
thick, creamy, and odor- 
less. In another group 
of cases the evidences of 
inflammation of the 
pleura are much less 
marked, and in some they 
may be slight. There is 
but little fibrin in the 
exudate, and adhesions 
are rare. In this form 
the streptococcus or the 
staphylococcus is the or- 
ganism usually found. 
In these cases the inflam- 
mation may be purulent from the outset, and the pus is thinner than 
in the preceding variety. Empyema following pneumonia is occasion- 
ally preceded by a serious effusion which, although almost clear, is 
usually found to contain great numbers of bacteria, usually pneumococci. 
Even when the fluid is moderate in quantity it is not all at the bottom 
of the chest, but is generally distributed over a considerable part of its 
surface, and its depth at the middle and upper part of the chest may 
be only half an inch, or even less. When the accumulation is larger, 
the lung does not float on the surface of the fluid, but the fluid sur- 
rounds the lung, which is compressed on all sides (Figs. 73, 74, 75). The 




Fig. 73. — Section of a Lung. To illustrate the dis- 
tribution of the fluid in the chest with a moderate 
effusion (diagrammatic) . 



EMPYEMA 



565 




Fig. 74. 



Empyema, Right Side; Moderate 
Effusion. 



heart is displaced; the diaphragm and the abdominal viscera are some- 
what depressed, and there may be bulging of the chest on the affected 
side. The amount of fluid in ordinary cases is from four to twenty 
ounces, although in neglected cases it may accumulate until it amounts 
to four or five pints. The effect 
upon the lung will depend upon 
the amount of fluid and the 
duration of the compression. 
"When the quantity is small, or 
when the pressure is removed 
early, the lung in most cases 
readily expands, air being forced 
into it from the opposite lung, 
especially during the act of 
coughing. With the exception 
of adhesions, recovery may be 
complete. Although wide in ex- 
tent, the adhesions are not 
usually strong enough to inter- 
fere seriously with the function 
of the lung. If the pressure is great and has been long continued. the 
adhesions over the lung may become so dense and firm that expansion is 
difficult, and can at best be only partial. In such cases recession of the 
chest wall occurs. In old cases expansion is still further interfered with 

by the changes taking place in 
the lung itself, usually a low 
grade of interstitial pneumonia. 
In cases receiving no treat- 
ment, absorption of the pus is 
possible, but is not to be ex- 
pected. It generally seeks an 
external outlet; the lung may be 
perforated and the pus be evac- 
uated through the bronchi, or 
external rupture may occur. 
generally in the neighborhood of 
the nipple. In still other eases 
the pus may burrow along the 
-pine, or through the diaphragm 
reaching the peritoneum. 
Empyema is more often of the left than of the righl side, the propor- 
tion being about three to two. Ii is double in about three per cent 
of all cases, but much oftener in infant-. The mosl ilicatioil 




Fig. 75. — Empyema with Large Effusion. 



566 



DISEASES OF THE RESPIRATORY SYSTEM 



in young children is pericarditis, usually with empyema of the left side; 
in older children a frequent complication is pulmonary tuberculosis. 

Symptoms. — When it occurs as a sequel of pneumonia, the symptoms 
of empyema may follow those of the original disease without any inter- 
mission; or after the temperature has been normal or nearly so for sev- 



DAY 


I 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


10 


17 


18 


19 


20 


21 


22 


23 


106 
105 
104 
103 
102 
101 
100 
99 


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Fig. 76. — Empyema following Pneumonia. Private patient, girl, eight years old; se- 
vere pneumonia terminating by lysis ; development of empyema indicated by second- 
ary temperature; operation on seventeenth day; recovery. 

eral days it may rise again, sometimes quite suddenly, but more often 
gradually. With this accession of fever there are other symptoms point- 
ing to an increase in the thoracic disease. (See Figs. 76 and 77.) 
After scarlet fever or other infectious diseases, the onset of empyema is 

often signalized by 
cough, rapid breath- 
ing, and the other 
usual symptoms of 
pulmonary disease. In 
the cases where em- 
pyema appears to be 
primary, the onset is 
acute, with high tem- 
perature and general 
and local symptoms 
resembling those of 
pneumonia. After such 
a beginning, the chest 
may be found full of 
pus by the third or fourth day. In older children empyema may come on 
with gradual, and even insidious symptoms, there being only slight fever, 
dyspnea, and cachexia. Marked leucocytosis, 25,000 to -40,000, is almost 
invariably present. The proportion of polymorphonuclear cells is usually 
from seventy-five to eighty-five per cent. 



DAY 


5 





7 


8 


9 


10 


11 


12 1 13 


14 


15 


10 


17 


18 


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105° 

104 
103 
102" 
101 
100 
99° 


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Fig. 77. — Empyema following Pneumonia. Hospital 
patient, two years old; single-lobe pneumonia with 
crisis on ninth day; no resolution, but instead gradual 
development of signs of empyema closely following 
the temperature curve. 



EMPYEMA 567 

Of 88 patients with empyema in the Babies' Hospital, nearly all under 
three years old, positive blood cultures were obtained in 41 per cent. The 
pneumococcus was the organism usually found. 

AYhatever may have been the mode of onset, when the pus has been 
in the chest for some time the symptoms are fairly uniform. During 
the acute stage there are present pallor, anemia, and prostration. The 
respirations are always accelerated, being usually from forty to seventy 
a minute. Cough is present; there is dyspnea, sometimes marked, but 
more often it is scarcely noticeable. The temperature is exceedingly 
variable; usually it ranges from 101° to 103° F. A typical hectic tem- 
perature with sweating is in our experience very rare. The pulse is 
rapid but of fair strength. There is loss of flesh, sometimes even emacia- 
tion and anorexia; occasionally there is diarrhea. The stage of acute 
symptoms may last from two to four weeks. This may be succeeded by 
a subacute stage which may last for months. In this there is little or no 
fever; the patient seems convalescent so far as regaining strength and 
color are concerned; but cough, dyspnea, and rapid respiration con- 
tinue. The chest shows no change in signs from those of the acute stage. 
In chronic cases the general symptoms closely resemble those of tubercu- 
losis. There may be clubbing of the fingers, albuminuria, swelling of the 
feet, and often marked lateral curvature of the spine. 

Diagnosis. — The physical signs do not differ essentially from those 
present in serous effusion. If there are signs of fluid in the chest and 
the patient is under three years of age, the fluid is likely to be purulenl ; 
and from the third to the seventh year, pus is much mure often found 
than serum. A marked leukocytosis always makes pus mure probable. In 
every case in which fluid is suspected the exploring needle should be 
used, because of the great importance of an early diagnosis. The skin 
should be surgically clean and the needle sterilized. Pus may nut be 
found because the needle is too small, too short, or because it is intro- 
duced too far into the chest; for when the layer of pus is thin, the 
needle may be pushed through this into the lung. 

The physical signs upon which must, reliance Is to be placed arc, 
marked dulness or flatness on percussion, feeble breathing, and displace- 
ment of the heart. When in a young child these signs are present, 
whether general ur localized, a needle should be inserted, and if pua is 
not found at the first trial, repealed punctures should be made until 
the presence or absence of fluid is definitely settled. 

Empyema is most frequently confounded with unresolved pneumonia. 
The differential points are that in unresolved pneumonia the dulness is 
usually over a single lobe, rales or friction sounds are heard, and there is 
no displacement of the heart; empyema may give flatness over the whole 
lung, or over the lower half of the chesl in I'mnt and behind, r&les and 



568 DISEASES OF THE RESPIRATORY SYSTEM 

friction sounds are absent over this area, and the heart is usually dis- 
placed. In both conditions we may get bronchial breathing and voice. 
The confusion of acute pneumonia or tuberculosis with empyema, gen- 
erally arises from placing too much reliance upon auscultation. In 
pleuropneumonia, with an excessive exudation of fibrin, the signs may 
be identical with those of empyema, except that the heart is not dis- 
placed. We have several times seen pulmonary tuberculosis, with casea- 
tion of an entire lobe, which gave signs that were identical with those 
of a sacculated empyema. It is by the exploring needle, and by that 
alone, that empyema is positively differentiated from these pulmonary 
conditions. 

There are some other thoracic diseases from which the diagnosis may 
be even more difficult. A large pericardial effusion gives signs which 
are in some cases identical with those of empyema of the left side. 
Marked displacement of the heart to the right is always a strong point 
in favor of empyema; besides, such pericardial effusions are extremely 
rare in young children. A pulmonary abscess of considerable size — also 
a rare condition — gives signs identical with those of localized empyema, 
and is only distinguished from it by autopsy or operation. Abscesses 
from broken-down tuberculous glands may give signs resembling those 
of localized empyema, and like an empyema may point between the ribs 
in the upper part of the chest. The constitutional symptoms of empyema 
may at times resemble typhoid fever or malaria; but it is distin- 
guished from them by the physical signs and by the examination of 
the blood. 

Prognosis. — The outcome of a case of empyema depends chiefly upon 
the age and general condition of the patient, the exciting cause, the 
duration of the symptoms, the presence or absence of serious complica- 
tions, and the treatment. The mortality in young children is high, 
particularly in the first year. Of 204 consecutive cases admitted to the 
Babies' Hospital, the death rate was as follows : 

First year 74 cases ; mortality 74 per cent 

Second " 93 " " 59 " 

Over two years 37 " " 13 " 

It is often difficult to understand why the cases in infancy do so 
badly; many of these children on admission are in excellent condition 
and do well for a week or more after operation. Then the temperature 
rises, the patients lose ground rapidly and die of exhaustion during the 
third or fourth week. Their inability to expand the compressed lung 
properly seems an important factor, as this condition is almost invariably 
found at autopsy. Very seldom is there trouble with drainage. Em- 



EMPYEMA 569 

pyema in children over three years old seen reasonably early and receiving 
proper treatment, almost invariably terminates in recoverv, unless the 
disease is donble or serious complications exist. The best results are 
seen in the cases that follow pneumonia. Pneumococcus and staphylo- 
coccus cases have a better outlook than those due to the streptococcus 
or to mixed infections. Tuberculosis before the seventh year is an ex- 
ceedingly infrequent cause, and gangrene of the lung and general pyemia 
are both rare causes in early life. It is these three conditions that make 
the prognosis of the disease in adults so serious. Great delay in opera- 
tion makes the prognosis .worse, because the more difficult the expansion 
of the lung the more tedious is the disease, and the greater the likelihood 
of a sinus remaining. With proper early treatment these patients not 
only recover, but in most cases the recovery is surprisingly complete. 
Eetraction of the -chest and its resulting lateral curvature of the spine 
are rare, and seen only in neglected cases. In very many patients, in 
which a reasonably early operation was done, it is impossible, after the 
lapse of two or three years, to detect any difference whatever in the 
physical signs of the two sides of the chest. There are few serious 
diseases the treatment of which is more satisfactory than that of acute 
empyema in older children. 

Spontaneous recovery in empyema may take place by absorption ; but 
this is so rare that it is not to be expected. The pus may be evacuated 
spontaneously through a bronchus, rupture having taken place through 
the visceral pleura. When this occurs, a large amount of pus may he 
coughed up in a few hours, usually followed by immediate, but not 
always lasting, improvement. This is the most favorable of the natural 
terminations. External opening may take place, usually in the region <>t' 
the nipple. There is an area of redness, then a fluctuating tumor, and 
finally the pointing of an abscess. The discharge may continue for 
months, or even for years. External opening rarely occurs until the dis- 
ease has lasted several months. Of 1!) cases of empyema in children 
collected by Schmidt, in which a spontaneous discharge of pus occurred 
either externally or through a bronchus, there were 1« deaths and 2 
recoveries. Empyema may burrow behind the diaphragm into the ab- 
dominal cavity, appearing as a psoas abscess; it may burrow posteriorly 
into the lumbar region: it may rupture into the esophagus, or through 
the diaphragm into the perit< a) cavity. All these c litions, how- 
ever, are very rare. The chances of spontaneous cure in empyema are 
small. Of 32 cases, reported by Rilliel and Barthez, which received 
no surgical treatment. 21 proved fatal. The statistics of empyema he- 
fore the general adoption of surgical treatmenl are appalling. Patienta 
were either worn out by the protracted suppuration, or died from amyloid 
degeneration, pneumonia, or tuberculosis. 



570 DISEASES OF THE RESPIRATORY SYSTEM 

Treatment. — The medical treatment relates to the patient only; the 
disease is always to be treated surgically. Like any other acute abscess, 
empyema requires free incision and drainage with proper aseptic pre- 
cautions. 

Aspiration as a means of cure is now seldom used. Unquestionably 
it sometimes suffices to cure empyema, most frequently when it is local- 
ized, and when the cause is the staphylococcus. How often this occurs 
is shown by the following statistics : Of 139 cases which we collected 
that were treated by aspiration, 25 were cured, 8 of these by a single 
aspiration; 13 died, and the remaining 101 were afterward subjected to 
other treatment. The objections to aspiration are, that it is not possible 
to remove all the pus; that it affords no opportunity for the removal of 
the large fibrinous masses; besides, there is the danger, especially will) 
repeated aspirations, of puncturing the lung and producing pneu- 
mothorax. Simple aspiration, therefore, is to be advised in children 
only for temporary relief when the amount of fluid is large and the 
patient's condition such as to make it desirable to defer any more serious 
operation. It is to be advised also in the case of double empyema until 
sufficient adhesions have formed upon the first side operated upon to 
make opening of the other pleural cavity safe. Aspiration, followed by 
the injection of formalin and glycerin, is not, from our experience, to 
be recommended. 

Incision and Drainage. — In most cases it is preferable to delay 
incision until the period of most acute inflammation has subsided, as 
shown by lower temperature and stationary physical signs. This is 
usually seen two or three weeks after the pleural invasion. Such delay 
is not admissible if either the local condition or the temperature points 
to a steady increase in the disease; nor when the general symptoms 
indicate increasing prostration or sepsis. The dangers attendant upon 
general anesthesia are considerable, and in most cases it is better not to 
employ it. We have known of six deaths on the table during operation, 
and in several other cases have seen very alarming symptoms occur. 
Chloroform is more to be feared than ether. It is well, when possible, 
to employ local anesthesia. The most favorable point for incision is the 
posterior axillary line in the seventh intercostal space upon the right 
side, the eighth upon the left. In a case of localized empyema, the 
lowest point at which pus can be obtained by puncture should be chosen. 
The incision is made in the middle of the intercostal space. No matter 
what has been found by puncture on previous occasions, the exploring 
needle should always be used at the time of operation and at the site 
of the incision before the latter is made. The incision should be only 
large enough to allow the introduction of two tubes side by side into the 
pleural cavity. The hemorrhage is very rarely sufficient to require a 



EMPYEMA 571 

ligature. It is undesirable to attempt to empty the chest at the time 
of operation. A better plan is to insert the tubes at once and apply the 
dressings, allowing the pus to escape slowly. The drainage tubes should 
be of rubber, fenestrated, one-fourth to three-eighths of an inch in 
diameter and about three inches long. To secure them from slipping 
into the cavity, the outer end should be transfixed by a large safety-pin 
before introduction. 

Both the original operation and the subsequent dressings should be 
done with strict aseptic precautions on account of the danger of sec- 
ondary infection, the occurrence of which adds to the severity and pro- 
longs the course of the disease. After the third or fourth day the second 
tube may be omitted and the remaining one gradually shortened. Often, 
by the end of the fourth week, and sometimes before, the tube may be 
dispensed with altogether. The time of redressing and the removal of 
the tube is determined by the amount of discharge and the tem- 
perature. 

Simple incision with drainage is in infants to be preferred to rib 
resection. It requires less time, no general anesthetic, and is altogether 
a much less severe operation. Our experience is that following it pul- 
monary expansion takes place with more facility than when a large 
opening is made in the chest, and that in the great majority of cases 
it secures all the room required for drainage. There are, however, some 
disadvantages. The smaller opening may not give adequate room for 
the removal of large masses of fibrin. In old cases, particularly, it not 
infrequently happens that after the chest has been emptied the ribs 
become so closely approximated that but little space is left, and the 
drainage tubes are pinched. Furthermore, the contact of the tubes may 
lead to erosion and superficial necrosis of the adjacent ribs, sometimes 
to exostoses. 

Incision tvith Bib Resection. — This is the operation to be preferred 
with children over three or four years of age. It is sometimes needed 
as a secondary operation in cases which cannot be properly drained by 
the simple incision owing to approximation of the ribs. The removal of 
an inch of rib is usually all that is necessary. This allows the insertion 
of the finger into the chest, the removal of masses of fibrin and the 
breaking down of adhesions if any are present, and il secures free 
drainage. The extensive manipulation which is sometimes practiced in 
these cases with older patients is not admissible with young children. 

Siphon Drainage. — This method of treatment introduced many years 
ago by Bulau and recently revised and improved by Kcnvon has much 
to commend it for young infants. The opening made into the chest 
is a very small one admitting only a single large drainage tube. The 
wound is tightly strapped about the tube so as to exclude air. The 



572 



DISEASES OF THE RESPIRATORY SYSTEM 



/ 



thoracic tube is connected by a glass tube with several feet of rubber 
tubing and this with the wash bottle which contains a sterile salt solu- 
tion. This bottle is suspended beneath the patient's bed or placed 
upon the floor. The character and the amount of discharge can thus 
readily be seen. As the tube often need not be changed for several 

days the child is spared the fa- 
tigue and distress of frequent 
dressings. The exclusion of air 
diminishes the danger of sec- 
ondary infection and favors the 
expansion of the lung. The bot- 
tle is emptied once or twice a day, 
the air being meanwhile excluded 
by clamping the tube. The chief 
objection to this method of treat- 
ment is interference with drain- 
age by the blocking of the tube. 
Such an occurrence is at once 
recognized by inspection of the 
fluid in the wash bottle. A fibrin* 
plug can sometimes be removed 
by suction, or by raising the bot- 
tle and allowing some of the ster- 
ile solution to floAv into the chest, 
afterwards siphoning it out; but 
in many cases the tube must be 
removed to clear it. Even if this 
is carefully done by keeping a 
tight pad on the wound, air can- 
not be excluded from the chest 
nor secondary infection of the 
pleura entirely avoided. When 
repeated blocking of the tube oc- 
curs the treatment may have to 
be discontinued. The tube can 
usually be worn for ten or twelve 
days, after which it loosens owing 
to ulceration about it and an air- 
tight wound can no longer be 
maintained. The short tube with the dressing of gauze and cotton is 
substituted. An extensive trial of siphon drainage leads us to recommend 
its use in many cases of empyema in infants. 

Washing out the pleural cavity is indicated in cases in which 




k 



Fig. 78. — Deformity after an Old Em- 
pyema of the Left Side for which 
Estlander's Operation was Per- 
formed. Portions of five ribs were 
removed. (From a photograph seven 
years after operation.) 



EMPYEMA 



570 



the pus is foul. A single washing for the purpose of removing fibrin 
is the routine practice of some surgeons. For this a warm, sterilized salt 
solution should be used. Personally, we have seldom found this neces- 
sary. Kepeated irrigations should not be employed. The usual dura- 
tion of the discharge in cases treated by simple incision is from three 
to six weeks, the average being about five weeks. 

A persistence of temperature or a fresh rise after operation most 
frequently indicates defective drainage, generally due to blocking of 
the tube ; but this is not always the case. It may be due to pneumonia, 
either a continuance of the old process or the lighting up of a new one, 
to abscess of the lung, to 
empyema of the opposite 
side, to pericarditis, or to. 
some cause outside the 
chest, very frequently oti- 
tis. The mistake is often 
made of allowing the tube 
to remain for too long a 
time, so that a sinus is 
kept open which would 
otherwise close. 

In chronic cases, or 
those which have been long 
neglected, some further 
operative treatment is 
often necessary. The lung 
is so bound down by firm 
adhesions that further ex- 
pansion is impossible, and 
even after the chest has re- 
ceded to its utmost, so that the ribs are in contact, there still remains a 
cavity which cannot close. For such cases the only hope is an operation 
by which portions of several ribs are removed, thus allowing a greater 
collapse of the chest wall. This is known as "thoraplasty," or "Estland- 
er's operation/' The operation is of itself a serious one, and only to be 
advised as a last resort in inveterate cases. Such an operation is, of 
course, always followed by very great deformity (Fig. 78). 

Methods of Inducing Expansion of the Lung. — In most of the cases, 
particularly the recent ones, complete expansion of the lung takes place 
without any difficulty, the chief agent being the cough. In Bome cases 
this may be insufficient. The apparatus, devised by James, shown in 
the accompanying cut (Fig. 79), serves at the same time as a toy for 
the child's amusement and as a most efficienl means of inducing forced 
20 




Fig. 79. — James's Apparatus for Expanding thk 
Lung after Empye.m\. 



574 DISEASES OF THE RESPIRATORY SYSTEM 

expiration. One bottle is placed a few inches higher than the other, and 
the child blows a colored fluid from the lower into the higher bottle, 
allowing it to siphon back. Blowing soap bubbles often answers the 
same purpose. 



SECTION V 
DISEASES OF THE CIRCULATORY SYSTEM 

CHAPTER I 
PECULIARITIES OF THE HEART AND CIRCULATION IN EARLY LIFE 

The Fetal Circulation. — During the latter part of fetal life the cir- 
culation may be briefly described as follows: The purified blood comes 
from the placenta through the umbilical vein. Entering the body, it 
divides at the under surface of the liver into two branches, the smaller 
one, the ductus venosus, communicating directly with the inferior vena 
cava; the larger branch joining the portal vein, so that its blood traverses 
the liver, and then enters the inferior vena cava through the hepatic 
vein. From the inferior vena cava the blood enters the right auricle, like 
that returned from the head and upper extremities by the superior vena 
cava. A part of the blood now passes directly into the left auricle 
through the foramen ovale; the remainder, through the tricuspid orifice 
into the right ventricle. As the requirements of the pulmonary circula- 
tion are not great, only a small part of the blood is sent through tin 1 
pulmonary artery to the lungs; the greater portion passes from the 
pulmonary artery through the ductus arteriosus into the aorta, joining 
here the blood from the left ventricle. The blood thus finds its wav 
from the right heart to the left, only iu small part by way of the lungs, 
the greater part passing directly from the fight auricle to the left, or 
from the right ventricle into the aorta through the ductus arteriosus. 
From the aorta, the blood reaches the placenta through the umbilical 
arteries, which are a continuation of the hypogastric arteries, which 
in turn are given off from the internal iliaes. 

Changes in the Circulation at Birth. — With the ligation of the 
umbilical cord, the circulation through the umbilical vein and arteries 
and the ductus venosus ceases. With the establishment of respiration 
and the Consequent increased demands made by the pulmonary circula- 
tion, the blood censes almost at once to pass through the ductus arterio- 
sus, and very soon through the foramen ovate. The umbilical vessels 
during the first few days of life are filled with small thrombi, which be- 
come organized. By the end of the first week, these vessels, ;i- wrell a.- the 

575 



576 DISEASES OF THE CIRCULATORY SYSTEM 

ductus venosus, are usually closed at their extremities, although they may 
remain patulous throughout the greater part of their extent for several 
weeks. They subsequently atrophy to the condition of small fibrous 
cords. For some weeks before birth the circulation through the foramen 
ovale is slight, it being gradually obstructed by the growth of a septum 
which nearly fills the space at birth. After the first week of extra-uterine 
life very little, if any, blood passes through it, although complete closure 
of the foramen often does not take place until the middle of the first year. 
In fully one-fourth of the autopsies we have made upon infants under six 
months old, there have been found minute openings at the margin of the 
foramen ovale, but they are usually oblique, and closed by the valvular 
curtain so as effectually to obstruct the current of blood. The ductus 
arteriosus is first closed by a clot, which becomes organized and blends 
with the products of a proliferating arteritis. It is rarely found open after 
the tenth day, and by the twentieth it is almost invariably obliterated. 

Size and Growth of the Heart. — The relative size of the heart is 
slightly greater in infancy than in later life, it being smallest at about 
the seventh year. The average weight at the different periods of life is 
as follows: 

The growth of the heart is rapid during the first three years, and 
nearly proportionate to that of the body. It is slowest from the third 
to the tenth year, and most rapid from the eleventh to the fifteenth 
year. At birth, the thickness of the right ventricle is very nearly the 
same as that of the left, the ratio being 6 : 7. The left ventricle, how- 
ever, grows very much more rapidly than the right, so that at the end 
of the second year the ratio is 1 : 2, which is nearly that of the rest of 
childhood. 

The Pulse. — The pulse in early life is not only more frequent, but it 
is very much more variable than in adults. The following is the average 
pulse-rate in healthy children during sleep or perfect quiet: 

Six to twelve months 105 to 115 per minute. 

Two to six years 90 " 105 * * 

Seven to ten years 80 " 90 " " 

Eleven to fourteen years 75 " 85 " " 

The pulse is a little more frequent in females than in males, and more 
frequent when sitting than when lying down. Muscular exercise or ex- 
citement increases the pulse-rate by from twenty to fifty beats. Very 
trivial causes disturb not only the frequency but the force of the pulse. 
The pulse in young infants may be irregular even in health and during 
sleep. When rapid, it is frequently irregular without special significance. 
No dicrotism is seen in the pulse wave of early infancy. 

The circulation is much more active in infancy than in later child- 
hood; thus, according to Vierordt, the entire round of the circulation is 



EXAMINATION OF THE HEART 577 

accomplished in the newly born in twelve seconds; at three years, in 
fifteen seconds; in the adult, in twenty-two seconds. 



Age. 


Ounces. 


Gram3. 


Ratio to Body 
Weight. 


Birth 


0.50 
1.25 
1.87 
2.25 

2.80 
5.84 
8.50 


14 1 

35 I 
53 | 
64 J 
80 
166 
241 




1 year 




2 years 


1 to 225 


3 " 




7 " 


1 to 280 


14 « 


1 to 222 


Adult 


1 to 220 



The figures in infancy are from one hundred and fifty-five observations made 
in the New York Infant Asylum; the others are taken from Sahli. 

Position of the Apex Beat. — In the infant the heart is placed some- 
what higher, and occupies a position a little nearer the horizontal than 
in the adult. This is partly due to the higher position of the dia- 
phragm. The apex beat is therefore higher and farther to the left than 
in adult life. According to the observations of Wassilewski and Starck, 
whose combined examinations with reference to this point were made 
upon over 2,100 children, the apex beat is, as a rule, outside the mam- 
mary line until the fourth year; if it is less than one-third of an inch 
beyond the nipple, it can not be considered abnormal. From the fourth 
to the ninth year, the apex beat is in or near the mammary line. After 
the thirteenth year, under normal conditions, if is invariably within 
that line. During the first year the apex beat is usually found in the 
fourth intercostal space; from the first to the seventh year, it is found 
with about equal frequency in the fourth and the fifth spaces; after the 
seventh it is usually, and after the thirteenth year it is always, when 
normal, in the fifth space. The position of the apex beat may be con- 
siderably modified by severe deformities of the chest resulting from 
rickets, Pott's disease, or lateral curvature of the spine. 

Examination of the Heart. — Inspection. — Bulging of the precordium 
is a frequent and important sign of cardiac disease during childhood. 
The cardiac impulse is generally weaker than in the adult, and often it Is 
difficult to locate the apex beat owing to the thick layer of adipose tissue 
covering the chest. 

Palpation. — This is usually a much more satisfactory method than is 
inspection for determining the position of the apes beat. For this pur- 
pose the child should be in the sitting posture, with the body inclined 
slightly forward. Great displacemeni of the apex beat is always signifi- 
cant, and should lead one to suspeci pleuritic effusion; lesser degrees of 
displacement to the left indicate hypertrophy, especially of the left ven- 
tricle; epigastric pulsation indicates hypertrophy of the right ventricle. 



578 DISEASES OF THE CIRCULATORY SYSTEM 

Percussion. — This may be done either by the finger or the percussion 
hammer. A light blow should be used, on account of the thinness and 
elasticity of the chest walls. In percussing the heart, changes in the 
percussion note are generally better appreciated if one proceeds from the 
lung toward the heart rather than in the opposite direction. The outline 
of the area of "relative" or deep cardiac dulness, especially in small 
children, is proportionately larger than in the adult. This may lead to 
the mistaken opinion that the heart is enlarged, when it is really of nor- 
mal size. The upper boundary of this area is at the second interspace or 
the upper border of the third costal cartilage, at the left margin of the 
sternum; from this point the line of dulness extends in a curved direc- 
tion outward and downward, the extreme left limit being at or slightly 
beyond the mammary line at the fourth interspace. On the right side 
the line of dulness extends downward from the second interspace in a 
slightly curved direction along the parasternal line. The lower border 
is indeterminable on account of the liver. 

The area of "absolute" or superficial cardiac dulness, or that part 
of the heart uncovered by the lung, resembles in shape the same area in 
the adult, but it is relatively larger. 

Auscultation. — This is of little value unless the child is quiet. For 
an accurate diagnosis the stethoscope is indispensable, but auscultation 
should always be practiced with the naked ear as well. The rhythm and 
rapidity of the child's heart action are much more easily disturbed than 
are the adult's, and such disturbances are consequently much less sig- 
nificant. The rapidity of the heart in infancy is ordinarily so great as 
to make it difficult to determine the exact period in the cardiac cycle at 
which a murmur occurs. Normally, the loudest sound is the first sound 
at the apex; the weakest sound is the second sound at the aortic orifice. 
The prdmonary second sound is regularly louder than the second aortic 
up to the fourteenth year and in some children almost to adult life. 

In consequence of the small size and the thin walls of the chest, all 
sounds, both normal and pathological, appear relatively louder than in 
the adult, and the area of diffusion is therefore much greater. Thus it is 
a frequent occurrence for murmurs to be heard all over the chest both in 
front and behind. 

Reduplication of the heart sounds, in consequence of the valves of 
the two sides not closing exactly together, is not uncommon in children, 
and may be due simply to excitement. During the first four years of 
life nearly all the abnormal murmurs heard are systolic. Accidental 
murmurs are very common. They may be due to anemia and to many 
other conditions; although not so common as in older patients, they are 
by no means rare in infants. 

In older children, especially when lying on the left side, there is 



CONGENITAL ANOMALIES 579 

often heard a sound in the early part of diastole, the so-called "third 
heart sound." This is only heard in the region of the apex and always 
follows the second sound by an interval longer than occurs in true re- 
duplication. The sound has the character of a dull, distant thud. It 
is never blowing. The sound probably results from the sudden tension 
of the auriculoventricular valves produced by the rapid entrance of blood 
into the ventricle. It should be recognized that this sound is not an 
abnormality. Failure to do so may cause errors in diagnosis. 



CHAPTER II 
CONGENITAL ANOMALIES OF THE HEART 

Etiology. — Of the causes of congenital cardiac disease little is defi- 
nitely known. It occurs more often in first-born children than later 
ones; 16 of 50 cases being in first children (Still). It is often associated 
with other forms of imperfect development, notably of the brain, as 
in Mongolian idiocy. An attempt has been made to connect cardiac 
malformations with syphilis. A syphilitic family history is very sel- 
dom found; but Warthin has brought forward additional reason for 
suspecting syphilis since he has found that a positive Wassermann test 
is given by some of the children with congenital cardiac disease, but in 
our experience this has not been found with sufficient frequency to 
establish a causal relation. There has not been adduced any evidence to 
show that rheumatism plays a part. 

Lesions. — The congenital anomalies of the heart may be grouped 
under three general heads: 

1. Malformations resulting from imperfect development of eertaiu 
parts of the heart, most frequently one- of the septa. Either the ven- 
tricular or the auricular septum may he affected, or that dividing the 
pulmonary artery from the aorta. Such failure in development per- 
petuates conditions which are normal in Hie early months of fetal life. 
There may also be atresia of any one of the orifices, absence of one or 
more of the valvular leaflets, or of any one of the large vessels. 

2. The results of fetal endocarditis. The effects of this condition 
vary according to the time of its occurrence. It: is almost invariably of 
the right side, most frequently affecting the pulmonic valves. Valvular 
disease in fetal life leads not only to hypertrophy and dilatation, but 
also interferes with the normal developmenl of the heaiH by preventing 
the closure of the auricular or ventricular septum or the ductus arterio- 
sus, these being kept open by way of compensation. It ie not i tear h.iw 



580 DISEASES OF THE CIRCULATORY SYSTEM 

important a part fetal endocarditis plays in the production of con- 
genital lesions, certainly not so important a one as it was formerly 
believed. 

3. Persistence of fetal conditions, such as the foramen ovale or duc- 
tus arteriosus. This is usually by way of compensating for some mal- 
formation the result of imperfect development or of fetal endocarditis. 
Very rarely a fetal condition may persist when no sufficient reason for it 
can be found. 

In the following table are given the lesions found in two hundred and 
forty-two cases collected from medical literature : 

Frequency of the different lesions in 2Jf2 autopsies upon cases of congen- 
ital cardiac anomaly 

Defect in the ventricular septum 149 cases; the only lesion in 5 cases. 

Defect in the auricular septum, or patent fora- 
men ovale 126 '' 

Pulmonic stenosis or atresia 108 ' 

Patent ductus arteriosus 68 ' 

Abnormalities in the origin of the great vessels '. 45 ' 

Pulmonic insufficiency 17 ' 

Tricuspid insufficiency 6 ' 

Tricuspid stenosis or atresia 3 ' 

Mitral insufficiency 1 ' 

Mitral stenosis or atresia 6 ' 

Aortic insufficiency 1 ' 

Aortic stenosis or atresia 6 ' 

Transposition of the heart 2 ' 

Ectocardia 1 ' 



The most frequent associated lesions 

Pulmonic stenosis with defect in the ventricu- 
lar septum 92 cases, the only lesions in 20 cases. 

Pulmonic stenosis, with defect in the auricular 

septum 52 " " " " " 8 " 

Defects in both septa 82 " " " " " 17 " 

Pulmonic stenosis with defects in both septa. . 36 " " " " "21 " 

From this table it will be seen that, in the great majority of cases, 
several lesions are present, the most frequent combinations being pul- 
monic stenosis with defective ventricular septum; pulmonic stenosis 
with defective auricular septum ; the three lesions associated ; or the first 
two with a patent ductus arteriosus. Stenosis of the isthmus of the 
aorta, although not noted in this series, is not a very uncommon lesion ; 
the obstruction is in the arch of the aorta beyond the point where the 
large vessels are given off. 

Defect in the Ventricular Septum. — This is the most frequent lesion 
in congenital cardiac disease, and in half the cases is associated with 
pulmonic stenosis. The defect is generally at the upper part of the 



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a 


" 9 


a « 


u 


" 6 


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« a 


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" 


u a 


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" 


« a 


a 


" 


a a 


a 


" 


a a 


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" 


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" 



CONGENITAL ANOMALIES 



581 



septum (Fig. 80). It is usually from one-fourth to one-half an inch 
in diameter, but not infrequently there is a large defect; or the septum 
may be entirely absent, the heart then consisting of but three cavities — 
two auricles and one ventricle. If the auricular septum also is wanting, 
as may be the case, the heart has but two cavities. Frequently there are 
also abnormalities in the origin of the great vessels. The pulmonary 
artery and the aorta may be given off from a common ventricle, or 
the aorta may arise partly from one ventricle and partly from the other. 
If pulmonic stenosis or atresia is 
present, the opening in the ven- 
tricular septum is conservative, 
affording a channel for the pas- 
sage of blood from the right to the 
left side of the heart. 

Patent Foramen Ovale, or De- 
fect in the Auricular Septum. — 
Although this is one of the most 
common congenital malforma- 
tions, it is not one of the most im- 
portant. It rarely occurs alone, 
but is frequently found with pul- 
monic stenosis or a defect in the 
ventricular septum. Small oblique 
openings in the auricular septum 
— usually at the foramen ovale — 
are not infrequently met with in 
autopsies upon young infants, but 
they are of no importance. In 
pathological conditions the open- 
ing is from one-fourth to one inch 
in diameter, and there may be more than one opening, 
septum is frequently secondary to pulmonic stenosis. 

Patent Ductus Arteriosus. — As a solitary lesion this is rare, but it is 
frequently associated with pulmonic stenosis, usually with a defeci in one 
or both septa. It is then one of the channels by which the blood may 
find its way to the lungs when the pulmonary orifice is obstructed. It 
is not a malformation, but simply the persistence of a fetal condi- 
tion usually necessitated by other changes in the heart. But the direc- 
tion of the blood current is the opposite of that which exists in fetal 
life. 

Pulmonic Stenosis. — This is one of the most frequent and most im- 
portant lesions. It was formerly looked upon as being often du< 
fetal endocarditis, but is now believed in most cases to be due to a failure 




Fig. 80. — Congenital Cardiac Disease. 
The left ventricle is shown with a defect 
in the ventricular septum, the opening 
being just beneath the aortic valve. 
(From a patient dying in the Babies' 
Hospital.) 



A defect in thii 



582 DISEASES OE THE CIRCULATORY SYSTEM 

of development of the infundibulum of the right ventricle. It is often 
a primary lesion, and when marked it is always accompanied by other 
changes, most frequently by a defect in one or both septa or by a patent 
dnctus arteriosus. This is important, as being more constantly asso- 
ciated with cyanosis than is any other congenital lesion. Most of the 
children who live beyond six or seven years with cyanosis have this 
lesion, always accompanied by others of a compensatory character. The 
amount of obstruction varies from a slight narrowing of the orifice to 
complete atresia. The seat of obstruction may be at the pulmonic orifice, 
in the conus arteriosus, or in the pulmonary artery just beyond the 
valves. If there is atresia, the pulmonary artery is very small, and may 
be rudimentary. 

Pulmonic Insufficiency. — This lesion is relatively rare. It is usually 
the result of fetal endocarditis, but there may be absence of the pul- 
monary valve. It is most frequently associated with a defect in the ven- 
tricular septum. 

Tricuspid, mitral, and aortic disease are very infrequent and usually 
seen in cases with multiple defects. Atresia or stenosis is much more 
common than insufficiency. 

At normalities in the Origin of the Large Vessels. — These are quite 
frequent; but, as will be seen from the table, they are always associated 
with other lesions. Three forms are seen : (1) Transposition of the large 
vessels — the pulmonary artery is given off from the left, and the aorta 
from the right ventricle. (2) Both arteries arise from a common 
trunk. This is usually due to an incomplete development of the lower 
part of the septum dividing the two arteries. Usually the pulmonary 
artery appears to be a branch of the aorta. This condition is fre- 
quently associated with other abnormalities, often with so large a defect 
in the ventricular septum that there is really but one ventricle. ( 3 ) The 
aorta has an abnormal origin, arising from the right ventricle, or partly 
from both ventricles. This also is associated with a large defect in the 
ventricular septum. When described as arising from both ventricles, the 
aorta is usually given off directly above the line of the septum. 

An abnormality in the number of valvular segments is quite fre- 
quent, but seldom impairs the valve's function. In rare cases a valve is 
rudimentary, and it may be absent, generally at the pulmonic or tri- 
cuspid orifice. Absence of the right auricle and absence of the pericar- 
dium have been recorded ; also opening of the pulmonary veins into the 
right auricle, and a single pulmonary artery. In one case in the series 
there was ectocardia, this being associated with a congenital fissure of 
the sternum. We have seen two very remarkable instances of congenital 
cardiac displacement; the heart was in both situated in the abdominal 
cavity. The pulsations could be plainly seen and felt just above the 



CONGENITAL ANOMALIES 583 

umbilicus. In each case there was a congenital defect of the abdominal 
walls and also an opening in the diaphragm. 

Transposition of the heart, or true dextrocardia, was recorded but 
twice in this series of cases. The transposition of the heart alone is a 
very rare condition. It is not so unusual to find transposition of all of 
the thoracic and abdominal viscera. In the last two years we have seen 
three such cases. 

Secondary Lesions. — In congenital malformations the right heart is 
usually found hypertrophied, since there are present one or more of the 
fetal conditions in which the greater part of the work is thrown upon 
the right ventricle. Such hypertrophy is in most cases accompanied by 
some dilatation. Changes in the muscular wall of the left heart alone 
are exceedingly rare. In four cases there was evidence of malignant 
endocarditis which was the cause of death, all but one of these patients 
being adults. 

Symptoms. — The symptoms of congenital cardiac disease are usually 
manifested soon after birth. Of T28 cases in whieh the time of the first 
symptoms was noted, they were congenital, or appeared during the 
first month, in 85 ; after one month and during the first year, in 18 ; 
from one to sixteen years, in 15; while in 10 no symptoms were observed 
until after puberty. Congenital cardiac disease is one of the causes, but 
not a frequent one, of death during the first days of life. 

The most striking objective symptom is cyanosis. This is present 
in most of the severe cases; but> considering all varieties, cyanosis is 
more often absent than present, and it may be absent even with serious 
lesions. It may be slight and noticed only upon exertion, as upon 
coughing or crying, or it may be intense and constant, giving the skin 
a dark, leaden color, and the mucous membrane of the mouth a rasp- 
berry hue. The view that cyanosis depends upon an admixture of 
arterial and venous blood is generally discredited. In the great ma- 
jority of the cases at least, the explanation is a deficient oxygenation of 
the blood in the lungs, owing to some interference with, the pulmonary 
circulation. In sixty-three per cent of the cases with cyanosis in the 
series, there was found pulmonic stenosis or atresia, or a small pulmonary 
artery. Cyanosis is of much value in diagnosis, as in acquired cardiac 
disease it is rarely persistent. The degree of cyanosis and its con- 
stancy are of some importance in determining the gravity of the lesion. 
although cyanosis alone is not to be depended upon. 

Another frequent symptom is the enlargement of the terminal 
phalanges known as clubbed or "drum-stick" fingers (Fig. si ) and in.-. 
This almost invariably accompanies cyanosis, and is generally propor- 
tionate to it. The enlargement, which usually involves all the phalai 
is probably due to venous obstruction. Occasionally there are seen d 



584 DISEASES OF THE CIRCULATORY SYSTEM 

ilea, edema of the face or lower extremities, dropsy of the serous cavities, 
and hemorrhages, particularly hemoptysis and epistaxis. 

There is generally marked dyspnea on exertion in the cases in which 
cyanosis is present ; but in most of those without cyanosis there is no 
dyspnea, and, in fact, no objective or subjective symptoms, even though 
the murmur may be very loud. The majority of the cyanotic children 
are undersized and develop slowly ; in them the problem of nutrition is a 
difficult one. 

In cases accompanied by cyanosis, or with obstruction to the pulmo- 



Fig. 81. — Clubbing of the Fingers in Congenital Heart Disease. (From a boy five 

years old.) 

nary circulation, a polycythemia is present. The increase in the number 
of red cells is generally proportionate to the cyanosis ; the average of fif- 
teen cases studied in the Yanderbilt Clinic by Wile was 7,495,000; the 
highest was 12,480,000. The hemoglobin is usually correspondingly 
increased. In the series mentioned the average was 107 per cent, the 
highest being 130. The number of white cells is changed very slightly, 
if at all ; the average in these cases was 10,200, which disproves the theory 
of blood concentration. The best explanation of the polycythemia seems 
to be that it is compensatory, and that the blood hypertrophies like 
other tissues. The blood-forming organs are stimulated to greater 
activity by the demands of the tissues for oxygen. The quantity of blood 
remains the same, but the number of red cells and the hemoglobin, and 



CONGENITAL ANOMALIES 585 

consequently the oxygen-carrying power, are very greatly increased. This 
in part compensates for the smaller amount of blood that can traverse 
the lungs and there become oxygenated. 

Diagnosis. — The most important diagnostic features are cyanosis, the 
presence of a loud murmur, and signs of enlargement of the right heart. 

Murmurs are present in fully nine-tenths of the cases. They are 
almost always systolic in time, are heard loudest to the left of the 
sternum, usually at the base or over the body of the heart, rarely at the 
apex. They are in most cases widely diffused, often being audible all 
over the chest. The point of maximum intensity is important for diag- 
nosis. In the great majority of cases only a single murmur is heard. 
A systolic murmur is usually due to pulmonic stenosis, deficient ventricu- 
lar septum or aortic stenosis, very rarely to mitral or tricuspid regurgita- 
tion. Since these conditions are very often associated, it may be difficult 
to tell upon which one the murmur depends. 

A patent ductus arteriosus usually gives a prolonged, continuous 
murmur with systolic intensification, which is loudest in the second or 
third left interspace. From the presence of a continuous murmur in a 
child, a diagnosis of patent ductus arteriosus can be made. The asso- 
ciated lesion is almost always pulmonary stenosis. In a young child, a 
loud murmur at the base of the heart with cyanosis almost always means 
congenital disease. A thrill is often present but it is not important for 
a diagnosis. 

Enlargement of the right heart, chiefly from ventricular hypertrophy, 
is present in most of the ca.es. 

A diagnosis of the precise nature of the malformation is very difficult, 
and in the great majority of cases only a probable diagnosis is possible. 
Nearly all the cases are complex, and the variety of combinations is very 
great. A study of the histories and autopsies of the cases in this scries 
reveals many apparently contradictory facts. Loud murmurs arc some- 
times heard which are difficult to explain by the lesions, and murmurs 
may be absent when there is every reason from the post-mortem findings 
for expecting their presence. With reference to the other conditions, 
we can not do better than give the more frequent clinical symptoms with 
the results of the autopsies in the series of cases which have been pre- 
sented. 

A Systolic Murmur at the Base with Cyanosis. — This was the mos1 
common combination met with, and was present in about one-third of 
the entire number. In over eighty per cent of the cases with these 
symptoms, pulmonic stenosis was found. The remainder were compli- 
cated cases of quite a wide variety. Pulmonic Btenosia was usually 
associated with a defect in one of the cardiac septa, or a patenl ductus 
arteriosus. 



586 DISEASES OF THE CIRCULATORY SYSTEM 

A Systolic Murmur without Cyanosis. — In this series of autopsies 
this was not a frequent combination, being noted but six times. It is 
usually dependent upon a defect in the ventricular septum without pul- 
monic stenosis. Clinically, however, this is more often seen, in fact it 
is one of the most common types. The murmur is generally loudest 
at the left margin of the sternum at the third space. There is a striking 
absence of all other symptoms. We have watched a number of such pa- 
tients grow to maturity and go through serious attacks of illness without 
showing any symptoms referable to the heart. 

A Systolic Murmur at the Apex with Cyanosis. — Of the six cases with 
this combination, all were examples of complex malformation, the most 
frequent lesions being a defect in the auricular septum, transposition of 
the great vessels, and patent ductus arteriosus. 

Cyanosis without murmurs was noted fourteen times. It usually in- 
dicates either pulmonic atresia or the transposition or irregular origin 
of the great vessels, but is sometimes seen when lesions such as usually 
give murmurs are found at autopsy. 

Diastolic murmurs were heard in but two cases, and depended upon 
pulmonic insufficiency. Diastolic murmurs are also heard when an 
acute endocarditis causing aortic or pulmonary insufficiency supervenes 
upon a congenital lesion. We have seen one such case and several have 
been reported. 

Absence of both cyanosis and murmurs was recorded in five cases. 
The lesions found were: atresia of the aorta, both arteries arising from 
the right ventricle, or defective septa. 

The only cases, therefore, in which a fairly certain anatomical diag- 
nosis can be made are those of pulmonic stenosis, deficient ventricular 
septum, and patent ductus arteriosus. 

Diagnosis of Congenital from Acquired Disease. — Congenital dis- 
ease may be suspected if the patient is under two years of age ; if there 
is no history of previous rheumatism; if the murmur is atypical in its 
location, character, or transmission; if there is a very loud murmur at 
the base or over the body of the heart, and if there is evidence of enlarge- 
ment of the right heart. If cyanosis and clubbing of the fingers are 
present the diagnosis is almost certain. 

Especially difficult are the cases without cyanosis seen in older chil- 
dren. But absence of hypertrophy of the left ventricle, continued absence 
of subjective symptoms, even with a very loud murmur, and a lesion 
which does not increase — all point strongly to a congenital malforma- 
tion. 

Diagnosis of Congenital from Accidental Murmurs. — This is often a 
more difficult matter than to decide between congenital and acquired dis- 
ease. From a murmur alone one slionld be very cautious in making a 



CONGENITAL ANOMALIES 587 

diagnosis of cardiac malformation in a very anemic infant. Anemic 
murmurs are systolic, usually basic, unaccompanied by enlargement of the 
heart, usually heard in the carotids, often in the subclavian arteries, but 
are seldom so loud as those due to malformations. In some cases it 
may be necessary to watch the progress of the case before deciding the 
question. 

It is not uncommon in children to find at about the level of the nipple 
at the left border of the sternum a soft systolic murmur best heard 
in the recumbent position, which, as it usually disappears, must be 
considered functional. It may be mistaken for a congenital murmur, 
but is not so loud. 

Prognosis. — Of 225 cases, 60 per cent were fatal before the end of 
the fifth year, and nearly one-half of these during the first two months; 
while sixteen per cent of the patients lived over sixteen years, and eight 
per cent over thirty years. The prognosis in cases without cyanosis is 
good; in many children the lesion has apparently little effect on the 
health or development. The prognosis is much worse in cases with 
cyanosis, and generally it is bad in proportion to the degree of cyanosis. 
The loudness of the murmur has no prognostic importance. 

In the cases fatal soon after birth the usual lesions are large defects 
in the septa, transposition of the great vessels, or pulmonic atresia. In 
five of twenty-three cases dying thus early, the heart had but two cavities. 
Lesions which are compatible with the longest life are minor septum 
defects, and pulmonic stenosis which can be compensated for by patency 
of the ductus arteriosus and in other ways. Many exceptional instances 
are recorded in which patients have lived a long time in spite of ex- 
treme deformities. One child with transposition of the pulmonary 
artery and aorta lived two and a half years. Tiedemann's patient lived 
eleven years with a heart consisting of three cavities — two auricles and 
one ventricle — and with constant cyanosis. In three eases reported by 
Rokitansky, the patients lived over forty years wiih rudimentary auric- 
ular septa; cyanosis is not mentioned as being present. Gelpke's patient, 
had cyanosis, and lived twenty-seven years with rudimentary auricular 
and ventricular septa, and with no tricuspid opening. Patients with 
serious congenital cardiac lesions are especially susceptible to pulmonary 
disease of all kinds and occasionally develop malignant endocarditis. 
Almost any acute illness may prove fatal. 

Treatment. — These patients are prone to develop at limes attacks 
resembling angina pectoris, which are \h'<{ relieved by nitroglycerin or 
by the use of morphin hypodermically. No treatment is of the slightesl 
avail in diminishing the amount of deformity or promoting the closure 
of any of the abnormal openings. All cases are to be treated sympto- 
matically. 



588 DISEASES OF THE CIRCULATORY SYSTEM 

CHAPTEE III 
PERICARDITIS 

Inflammation of the pericardium is uncommon in infancy and 
early childhood, only two cases being seen in 726 consecutive autopsies 
at the New York Infant Asylum. But in later childhood pericarditis 
is more frequent and more serious than the same disease in adults. 

Pericarditis is almost invariably a secondary disease, following (1) 
empyema or pleuropneumonia; (2) acute rheumatism; (3) acute in- 
fectious diseases, especially scarlet fever; (4) pyemia; (5) tuberculosis; 
(6) local conditions. The relative importance of these causes differs 
with the age of the child. In infancy and early childhood nearly all the 
cases complicate disease of the lung or pleura, more frequently of the 
left side. After the fourth year rheumatism takes the first place as an 
etiological factor. Pericarditis is then generally associated with endo- 
carditis, and may precede or follow the articular manifestations of rheu- 
matism. Following scarlet fever, pericarditis often occurs in connection 
with nephritis or multiple joint inflammations. In typhoid fever also 
it is usually associated with pneumonia or joint lesions. Pyemia may 
be a cause in the newly born, or it may occur in connection with disease 
of the bones or joints in older children; in both it is usually associated 
with similar lesions of other serous membranes. Tuberculous pericarditis 
is more frequent after the third year, and is generally secondary to pul- 
monary tuberculosis. Among the local causes may be mentioned trau- 
matism, ulceration of a foreign body from the esophagus into the peri- 
cardium, disease of the sternum, ribs, or vertebrae, and abscesses resulting 
from cheesy bronchial lymph nodes. 

Lesions. — Pericardial transudations, or an increase in the normal 
pericardial fluid, are met with in many conditions in which there is a 
very marked degree of anemia, general dropsy, or a weak heart, partic- 
ularly of the right side. Generally from one to two ounces of clear 
serum are found in the pericardial sac. 

Pneumococcus pericarditis is always acute and closely resembles in 
its lesions the inflammation of the pleura due to the same cause. In 
the milder cases there is seen only a fibrinous exudate. In the more 
common and more severe forms the visceral and parietal pericardium is 
covered with a thick coating of fibrin and pus (compare pleuropneu- 
monia), or more pus cells and serum may be poured out and the sac 
contain fluid pus. The amount is usually small, one-half to one ounce, 
but it may be as much as a pint. When the inflammation is excited by 
other pyogenic organisms, the staphylococcus or the streptococcus, the 
lesions are similar to those just described. 



PERICARDITIS 589 

Iii rheumatic pericarditis the inflammation may be a plastic one with 
a fibrino-cellular exudate (dry pericarditis) or sero-fibrinous (pericar- 
ditis with effusion). The inflammation generally begins at the base of 
the heart and affects both the visceral and parietal layers. The quantity 
of fluid present is usually small, not exceeding two or three ounces; ex- 
ceptionally as much as a pint may be present. It may be clear or 
slightly turbid. More important than the pericarditis are the associated 
changes in the heart muscle. These are present in every severe case. 
To the myocarditis and consequent dilatation the most serious symptoms 
of pericarditis are due. 

Purulent pericarditis may be set up by a foreign body ulcerating into 
the sac, by the rupture of a mediastinal abscess, or by general pyemia. 
In these circumstances the process may be purulent from the outset. 
Any of the pyogenic bacteria may be found. 

External or mediastinal pericarditis is always associated with medi- 
astinal pleurisy, and results in more or less extensive adhesions of the 
pericardial and pleural surfaces, with an increase in the connective tissue 
of the mediastinum. This is often a tuberculous process. When severe.. 
it may cause compression of the large blood-vessels, but seldom in any 
other way produces symptoms. With this form there is usually inflam- 
mation of the internal layer of the pericardium as well. Only inflamma- 
tion of the internal layer is ordinarily considered as pericarditis, the 
other form being preferably classed as mediastinitis. 

Pericarditis with an effusion of blood is very rare in children. It may 
occur from the rupture of organized adhesions or in certain blood states 
such as purpura, and very rarely in tuberculosis. 

With acute tuberculosis there is usually only a deposit of miliary 
tubercles, or there may be a small serous or sero-sangninoleni effusion. 
In chronic cases there may be a tuberculous inflammation with the for- 
mation of caseous nodules, new connective tissue, and extensive adhesions. 
This generally occurs in connection with pulmonary tuberculosis -some- 
times with tuberculous peritonitis. 

In any form of pericarditis complete recovery, so far as pathological 
conditions are concerned, is rare — if, indeed, it ever occurs. After a 
rheumatic pericarditis adhesions remain, which may be slight, but are 
often complete, causing entire obliteration of the pericardial sac. Such 
adhesions are followed by secondary changes. The growth and devel- 
opment of the heart are interfered with, and there may be sufficienl 
pressure upon the coronary vessels to lead to degeneration of the mus- 
cular walls and chronic dilatation of the heart. 

Symptoms. — A pericardial transudation, or dropsy of the pericar- 
dium, is very rarely large enough to make a diagnosis possible. 

External pericarditis is seldom recognized during life, there bei] 



590 DISEASES OF THE CIRCULATORY SYSTEM 

symptoms except those of the pleurisy with which it is associated. Occa- 
sionally there may be heard, particularly if the inflammation is anterior, 
a pleuritic friction sound which is increased with the systole of the 
heart. The pulse may be weak during inspiration, and there may be an 
increased area of cardiac dulness. If the inflammation is chiefly poste- 
rior, it causes only the symptoms of mediastinitis, which is recognized 
principally by its pressure effects upon the great vessels. It may produce 
edema of the face or of the lower extremities, ascites, enlargement of the 
liver and spleen, but rarely albuminuria. It is usually progressive, and 
lasts from a few months to two or three years, according to its cause. 

Pericarditis in infancy is usually overlooked, not only on account of 
its rarity, but also from the obscurity of its symptoms. When pericarditis 
develops at the height of an attack of pneumonia, as it usually does, 
there may be no new symptoms, or at most only increased prostration 
with perhaps a more rapid or slightly irregular pulse. On auscultation, 
if practiced early, one may hear pericardial friction sounds ; but these are 
masked by the pulmonary signs and in infants seldom made out. The 
most striking sign is that the cardiac sounds formerly distinct are now 
feeble and distant, at times almost inaudible. Later there may be in- 
creased dulness from pericardial effusion, or from dilatation. The phy- 
sician should be on the watch for it in infants with pleuropneumonia, 
especially of the left side. 

Eheumatic pericarditis affecting as it generally does older children 
is easier of recognition. Localized pain and tenderness are usually pres- 
ent and also a certain amount of embarrassment of the heart's action, 
manifested by precordial distress, palpitation, or a tumultuous heart 
action with a rapid and at times an irregular pulse. There is often vom- 
iting, dyspnea, and a teasing, dry cough; there may be orthopnea and 
some cyanosis. Sometimes there is delirium. 

The earliest physical sign of pericarditis is a friction sound which 
can generally be heard all over the precordium, though sometimes only 
over a small area at the base. The sound is usually a double, to-and-fro 
sound, synchronous with the movement of the heart. In character, the 
sound is rough, scratching or grating, not at all blowing in character, 
and, while it may be heard widely over the heart, is not transmitted. 
With the accumulation of the fluid, the friction sound may only be 
heard over a restricted area, but almost always persists at the base even 
though fluid may be present in large amount. It differs thus radically 
from the friction sound in pleurisy with effusion. Very early there 
is an increase in cardiac dulness which is often considerable. This 
may be due to effusion or to cardiac dilatation, which is apt to occur 
in all severe cases of pericarditis. With early and rapidly developing 
dulness it is safe to assume that some dilatation is present. The dulness 



PERICARDITIS 591 

can be made out both to the left and to the right of the heart. On the 
right side it is usually first noted in the fifth right intercostal space 
with an obliteration of the normal acute cardiohepatic angle, an obtuse 
angle resulting. The dulness usually does not extend more than an inch 
or two beyond the right border of the sternum and a similar distance 
beyond the left mammary line, but with very extensive effusion there 
may be dulness to the right of the right mammary line, and as far as the 
left anterior axillary line. (Figs. 82, 83.) 

The area of dulness with small effusions is triangular or pear-shaped 
with the base below. With large effusions it is almost circular, in which 




Fig. 82. — Pericarditis with Effusion. 
Anterior view, showing moderate dis- 
tention of the pericardium, especially 
to the left of the middle line; right 
border at A. Boy eight years old. 



Fig. 83. — Pericarditis with Effusion. 
Same patient as Fig. 82, but taken 
four days later. Great distention of 
the pericardium; right border at B. 
Complete recovery by absorption. 



case the cardiohepatic angle again becomes acute. There also may be 
dulness to the left of the vertebral column behind. When there is 
considerable effusion, the apex beat is feeble and may be displaced 
upward. It may be impossible to locate it. The cardiac sounds are 
diminished in intensity and may be almost inaudible. Of assistance in 
diagnosis is sometimes the disproportion between the cardiac sounds and 
the force of the pulse — the latter may be nearly normal when the cardiac 
sounds can barely be heard. As the result of pressure upon the lung from 
large accumulations of fluid, bronchial breathing may be heard poste- 
riorly, at and inside the spine of the scapula. 

In eases terminating fatally the progress of the disease is quite rapid, 
the entire duration being seldom longer than three or four weeks, and 
it may be much less. .Pneumonia often develops toward the close. When 
ending in recovery improvement is very slow ami i( may he two or three 
months before the patient is out of bed, and a much longer time before 
even a moderate degree of health is established. 

Prognosis. — Acute pericarditis due to the pneumococcus in infancy 



592 DISEASES OF THE CIRCULATORY SYSTEM 

almost invariably ends fatally and in older children this is the usual 
termination. Occasionally at the later age resolution may take place 
before pus forms, or the pyopericardium which ensues is successfully 
opened and drained. Purulent pericarditis from other causes is usually 
fatal. In rheumatic pericarditis the outlook for life is better, but this 
with its associated myocarditis is without doubt the gravest manifesta- 
tion of rheumatism in early life. ISTo complication is more to be dreaded, 
both on account of immediate and remote dangers. Of forty-eight cases 
of acute pericarditis reported by Still in which this supervened during 
endocarditis, forty proved fatal in the course of a few weeks. In patients 
who do not die from the disease the remote consequences by reason of 
adhesions and subsequent dilatation are very serious. 

Diagnosis.— -Pericarditis is recognized by knowing when to look for 
it — in infants with pneumonia, in older children with rheumatism. The 
difficulties of diagnosis of dry pericarditis are very much greater in young 
children owing to the very rapid action of the heart. Dry pericarditis 
is recognized by the friction sounds, which are best heard over the base 
and are to be differentiated from endocardial murmurs. Pericarditis 
with effusion is to be differentiated from dilatation of the heart and 
from pleuritic effusion. From dilatation, the diagnosis is very difficult in 
childhood, but the recognition of small effusions is not essential, since the 
important condition is the accompanying dilatation. Large effusions may 
be mistaken for a sacculated empyema of the left side; in the latter, 
however, the heart is generally crowded to the right. When empyema and 
pericarditis coexist, it may be impossible to recognize the condition. 
The diagnosis between serous and purulent effusions can be made only 
by aspiration. 

Treatment. — In an attack of acute pericarditis the patient should be 
kept in bed, absolutely quiet, and an ice-bag used over the heart. A 
layer of thin flannel should be placed beneath the bag. During the 
acute stage it should be applied constantly with perhaps a few hours' 
omission during the night. To be effective much attention to detail is 
necessary. Some children will not tolerate ice and for them dry heat 
may be substituted. It often mitigates the pain. Counter-irritation by 
mustard from time to time is useful, but blisters should not be employed 
in children. Leeching is much used in England, not so much in this 
country as its merits warrant. Four or five leeches are applied over 
the sternum or liver. The especial indications for the use of leeches 
are cyanosis, marked dyspnea, and dilatation as shown by increase in 
the cardiac dulness. A rapid increase in dulness is to be regarded as 
mainly due to dilatation rather than effusion. Opium is, in our opinion, 
of more value than any other drug. It has a steadying influence upon the 
excited heart, it relieves pain and also quiets the distressing cough. The 



CHRONIC PERICARDITIS WITH ADHESIONS £93 

form of administration is immaterial. The patient should be kept 
moderately under its influence throughout the active stage of the attack. 
Digitalis is sometimes useful, but must be used with caution. Alcohol 
is not indicated. Strychnin and caffein may be used when symptoms of 
heart failure are present ; but very little is to be expected from any drug. 
For the concurrent rheumatism anti-rheumatic remedies should usually 
be continued. Serous effusions usually subside under general treatment. 
With very large serous effusions aspiration may relieve distressing symp- 
toms, after which the rest of the fluid may undergo absorption. If the 
exploring needle shows the fluid to be purulent, incision and drainage 
should be practiced as in empyema. The results of aspiration for pyo- 
pericardium are exceedingly unfavorable. Of eighteen cases collected by 
Keating, only four recovered. In puncturing the pericardium the poini 
usually selected is a little to the left of the border of the sternum in the 
fifth intercostal space, the needle being directed upward and outward. In 
cases which do not end fatally a prolonged period of rest in bed is impera- 
tive on account of the dilatation. 



CHRONIC PERICARDITIS WITH ADHESIONS 

This is not a very uncommon condition. It is usually general, but 
may be localized. The youngest case which has come under our observa- 
tion was in a child sixteen months old, who died from acute broncho- 
pneumonia. . The adhesions were old and general, the pericardial sac 
being completely obliterated. Chronic adhesive pericarditis may follow 
single or repeated attacks of acute rheumatic pericarditis: it may be 
tuberculous. The pericardium may become very greatly thickened and its 
cavity obliterated; it may be adherent externally to the pleura, dia- 
phragm, and chest wall. Other changes are usually present in the heart. 
It is often the seat of chronic myocarditis; the cavities are usually greatly 
dilated, and the heart walls much hypertrophied. Valvular lesions may 
be present. 

Partial adhesions cause no symptoms by wliidi they can be recognized, 
and even general adhesions sufficient to obliterate the pericardial sac 
may be found at autopsy when not suspected during life. This is one of 
the conditions in which, after it has led to considerable dilatation of the 
heart, sudden death sometimes occurs. Usually there is pallor, slighl 
Cyanosis, localized edema of the chest and abdominal walls, and dyspnea 
upon slighl exertion: The liver and spleen are often enlarged and there 
may be ascites. These symptoms often lend to errors in diagnosis. 

The heart is almost invariably much enlarged, chiefly from dilatation. 



594 



DISEASES OF THE CIRCULATORY SYSTEM 



On inspection, there may be bulging of the chest wall, with a diffused 
and often feeble or absent apex beat. The characteristic signs are a 
systolic retraction of the chest at or near the apex of the heart, some- 
times at the tip of the sternum. This is due to the external pericardial 
adhesions, and is often better appreciated by palpation than by inspec- 
tion. It is followed by a rapid rebound, associated with diastolic collapse 
of the jugular veins. A pulsus paradoxicus may also be present. Percus- 
sion shows an increase in the cardiac dulness in all directions. The 
position of the apex and the percussion outline of the heart do not 
change with the posture of the patient, and the cardiac dulness is but 
little affected by full inspiration. A systolic murmur is often present. 
The diagnosis of adherent pericardium always presents difficulties, but 
it can be made with tolerable certainty in a considerable proportion of 
cases. On account of the enlargement of the heart and the frequency of 
murmurs, it is usually mistaken for valvular disease. The prognosis is 
very bad. The lesion is a permanent one, and tends to increase. The 
treatment is symptomatic. 



CHAPTER IV 



ENDOCARDITIS AND VALVULAR DISEASE OF THE HEART 

Endocakditis may occur even in fetal life. At this period it usu- 
ally affects the right side of the heart, and is one of the important causes 
of congenital malformations. In infancy, acute endocarditis is exceed- 
ingly rare, but a single instance being found in over two thousand autop- 
sies upon children under three years of age of which we have records. 
From the third to the fifth year it is less rare, and after five years is 
quite common. 

The following table gives the age and sex in a series of cases of 
valvular disease: 



Age. 


year. 


years. 


:j 


4 


years. 


6 

years. 


years. 


years. 



years. 


years. 


n 


12 


is 

years. 


14 

years. 


Totals. 


Males 




1 

1 


2 
3 


2 
5 


4 

7 


6 
9 


4 
10 


9 
3 


8 
11 


6 
12 


5 
14 


7 
4 


6 
2 


1 

3 


55, or 38% 






90, "62% 






Total 




2 


5 


7 


11 


15 


14 


12 


19 


18 


19 


11 


8 


4 


145 









The proportion as to sex is very nearly the same as in our cases of 
rheumatism. Sturges, in 100 cases of chronic endocarditis, gives fifty- 
six per cent females and forty-four per cent males. 



ENDOCARDITIS 595 

Endocarditis is usually spoken of as secondary to rheumatism : it is 
rather to be regarded as a manifestation, often the first, of that disease. 
Of 117 eases in our series, ninety-three, or eighty per cent, gave a 
history of previous rheumatism. Of the 31 cases which at the first 
examination gave no history of rheumatism, 8 subsequently developed 
articular symptoms, and 2 chorea; so that nearly ninety per cent of this 
series of cases presented conclusive evidence of a rheumatic diathesis. 
Thirty per cent had chorea previously, or developed it while under ob- 
servation. The proportion of rheumatic cases corresponds very closely 
with Cheadle's observations. In a series of 150 cases of valvular dis- 
ease, Still found distinct evidences of rheumatism in 142.* 

Endocarditis may occur alone or with other manifestations of rheu- 
matism. While frequently associated with acute articular rheumatism, 
in a much larger number it is seen with articular symptoms which are 
so slight as to be overlooked entirely or passed over as unimportant. It 
may occur with or folloAv chorea, tonsillitis, or torticollis, with or without 
articular symptoms. The proportion of rheumatic cases in which endo- 
carditis occurs is much larger in children than in adults. In rare in- 
stances endocarditis is seen in the course of almost any of the infectious 
diseases, most frequently with scarlet fever, being often associated with 
pericarditis; but even in these conditions it is possible that it is some- 
times rheumatic. The bacteriology of rheumatic endocarditis has not yet 
been determined with certainty. 

Lesions. — In the great majority of cases endocarditis affects the 
mitral valve, and often only this. In 150 autopsies upon children dying 
of cardiac disease, Poynton found the mitral valve involved in 149, but 
in 76 of these the changes were not marked ; in only 9 was there marked 
mitral stenosis. The aortic valve was affected in 51, but in only 9 was 
it seriously involved. Very striking was the frequency of pericarditis. 
Pericardial adhesions were present in 113 cases, and in 77 the adhesions 
were complete, i. e., the pericardial cavity was obliterated. These find- 
ings agree substantially with the observations of other English author- 
ities, but in America the pericardial lesions are certainly not so prom- 
inent. 

The pathological changes of acute endocarditis do not differ essen- 
tially in early life from those seen in adults. There is first an accumula- 
tion of bacteria upon the endocardium of the valves. These produce 
necrosis, which is followed by a clot formation, consisting chiefly of blood 
platelets and fibrin, in the meshes of which are Leukocytes and a Pew red 
cells. The next change is a growl It of aew connective i issue cells and 
blood-vessels, wliicli may be slight and superficial, bul the rheumatic 
lesion usually extends deeply with ;m extensive proliferation of connect ive 
tissue which after a time undergoes contraction. 



596 DISEASES OF THE CIRCULATORY SYSTEM 

In the mildest forms of endocarditis it is possible for complete re- 
covery to take place. In other cases there is left only a slight valvular 
thickening, not enough to interfere in any important way with function. 
In most patients, however, more marked changes are left. The valvular 
segments are swollen, adherent, somewhat shortened and consequently 
insufficient. Other changes in the heart usually accompany acute endo- 
carditis. Dilatation is almost invariably present and is an important 
factor in producing insufficiency. In cases ending fatally there is very 
little hypertrophy; but if recovery occurs, hypertrophy develops and the 
lesion is compensated for in this way. A certain amount of myocarditis 
probably occurs* in every severe case. It is most marked when pericar- 
ditis is also present. Emboli in children are rare. Subsequent attacks 
are exceedingly common and each one leaves the heart more seriously 
crippled. 

Chronic inflammation may follow the first attack or more often occur 
after repeated attacks. The changes resulting from chronic endocarditis 
are practically identical with those seen in adult life and need not be 
described here. Emphasis, however, should be laid upon the fact that 
the younger the child the more rapid the progress of the disease. 

Symptoms. — When endocarditis occurs as a primary disease, or when 
it is the only manifestation of rheumatism, it may begin abruptly with 
rather severe general symptoms — a temperature of 101° to 104° F., pros- 
tration, exaggerated heart action, restlessness, and sometimes dyspnea. 
More frequently, however, it begins much less acutely with only general 
malaise and slight fever, which often is not recognized without the ther- 
mometer. If the heart is not watched the diagnosis is not made and there 
may be no suspicion of the nature of the primary attack until some time 
afterward, when the existence of valvular disease is discovered. If, how- 
ever, the heart is carefully and frequently examined there is heard, usu- 
ally on the third or fourth day of the illness, a soft, blowing, systolic 
murmur at the apex. 

Endocarditis occurring with rheumatism is by no means limited to 
those attacks with well-defined articular symptoms. It is very common 
and often severe when the articular symptoms are no more than stiffness, 
pain on motion, arid slight swelling of the feet or ankles. There is no 
relation between the severity of these symptoms and the seriousness of 
the cardiac lesion. Occurring during chorea or after tonsillitis there may 
be nothing to call attention to the heart except sometimes an increased 
rapidity or irregularity of the pulse and possibly increased prostration; 
but frequently the cardiac condition is not suspected until the heart is 
examined. 

Most of the cases of acute endocarditis seen in this country are of this 
mild type. Attacks of such severity as to produce death in the acute 



CHRONIC VALVULAR DISEASE 597 

stage are relatively rare here, in marked contrast with the observations 
of English writers. 

The usual duration of acnte endocarditis is from two to four weeks, 
the general symptoms slowly subsiding and, if the case progresses favor- 
ably, the cardiac symptoms improve, but there is usually left behind a 
somewhat damaged heart because of valvular disease. In cases progress- 
ing unfavorably a fatal termination may come in the course of from two 
to six weeks owing usually to one of three causes or a combination of 
these: (1) The rapid development of dilatation accompanied by the 
usual signs of cardiac insufficiency; (2) pulmonary complications, gen- 
erally pneumonia; (3) the supervention of acute pericarditis. 

Course of Chronic Valvular Disease. — Chronic valvular disease fol- 
lows one or more attacks of acute endocarditis, and may exist for months 
and sometimes for years, before it is recognized. Its course is usually 
divided into two periods, the first being that in which compensation is 
present, and the second after compensation has failed. The duration of 
the stage of compensation is indefinite. The only subjective symptom 
that is of much diagnostic value is shortness of breath on exertion. Occa- 
sionally other symptoms are present, such as precordial pain, attacks of 
palpitation, headache, epistaxis, anemia, loss of weight, and cough. 
These are rarely constant, but come on when the patient's general con- 
dition for any reason is below normal. As a rule, there is in young 
subjects a tendency to an increase in the disease, although this is often 
slow, and may be interrupted by long periods in which the process ap- 
pears to be stationary. At such times the patients either have no symp- 
toms, or suffer only from a slight amount of inconvenience on marked 
exertion. 

Failure in compensation is generally brought aboul by one of the 
following causes: The most frequent is an intercurrent attack of rheu- 
matism with a fresh endocarditis, Which in a short lime leads to a very 
great increase in the heart's disability. It may he due to additional work 
thrown upon the heart from excessive muscular exertion, or i<> the strain 
of a prolonged attack of some acute illness, especially one thai is liable 
to produce changes in the heart muscle, such as typhoid, diphtheria, or 
scarlet fever. It is sometimes the increased work which is thrown upon 
the heart especially at the time of puberty, owing to the rapid growth 
of the body. It may result from any cause which seriously affects the 
patient's general nutrition, particularly when this is associated with 
marked anemia. 

The symptoms indicating failure of compensation are marked dysp- 
nea or orthopnea and cough, sometimes accompanied by profuse ex- 
pectoration, which may be bloody, and in rare cases there may he ],. 
pulmonary hemorrhages. With these may be associated other Big] 



598 DISEASES OF THE CIRCULATORY SYSTEM 

pulmonary congestion and even pulmonary edema. The obstruction to 
the systemic venous circulation leads to dropsy, which usually begins in 
the feet, sometimes in the face. There may be general anasarca and 
dropsy of the serous cavities, especially the peritoneum and pleura; also 
enlargement and functional disturbances of the liver, enlargement of the 
spleen, dyspeptic symptoms, and chronic congestion of the kidney, with 
scanty urine and albuminuria. There may be dilatation of the superficial 
veins and cyanosis; and there may be cerebral symptoms, such as head- 
ache, dizziness, and fainting attacks. The pulse is small and soft, and 
the heart's action rapid and irregular ; the cardiac sounds are feeble and 
often indistinguishable, and it may be impossible to decide what mur- 
murs, if any, are present. 

It is rare to see all the symptoms of chronic progressive cardiac fail- 
ure in children under seven years', but toward the time of puberty they 
are common enough. The symptoms may increase in severity until 
death occurs, or they may be severe for a time and then nearly disappear, 
to return again after a longer or shorter interval. 1 Death may be due to 
sudden cardiac paralysis, to intercurrent nephritis, pneumonia, embolism, 
inflammation of the serous membranes, or to edema of the lungs. 

Physical Signs. — Mitral murmurs are altogether the most common 

1 The course and termination of these cases of chronic valvular disease is 
well illustrated by the following history of a little girl who was under observa- 
tion for nine years : When first seen she was seven years old, and gave a his- 
tory of cardiac symptoms for one year. There was then present a loud mitral 
regurgitant murmur, with considerable hypertrophy. There was general dropsy, 
and all the symptoms pointed toward acute dilatation. Under treatment, the 
dropsy and other symptoms disappeared, and she went on comfortably for over 
a year. In her eighth and ninth years there were frequent attacks of subacute 
rheumatism, during which time the heart lesion steadily increased in severity. 
At twelve years there was an eruption of subcutaneous tendinous nodules, which 
remained for over two years. During this year there was heard for the first 
time a presystolic mitral murmur, accompanied by a very marked thrill, mitral 
stenosis having been gradually brought about by the slowly progressing endo- 
carditis. This murmur gradually increased in intensity from that time, while 
the mitral regurgitant murmur became less distinct. The apex beat was then in 
the sixth space, two and a half inches to the left of the nipple. From the 
twelfth to the fifteenth year she grew very little in height or weight, and showed 
no signs of maturity, the cardiac symptoms being nearly stationary. In the 
fifteenth year she developed a marked enlargement of the liver and spleen with 
general dropsy and all the symptoms of cardiac insufficiency, these being the 
first symptoms of this character since she was seven years old. There was now 
heard for the first time an aortic regurgitant murmur in addition to the others 
formerly present. The symptoms disappeared under treatment in the course 
of a few months, but six months later returned with greater severity and were 
accompanied by albuminuria, the patient dying from heart failure in a few 
weeks. During the last exacerbation there was heard a double aortic as well as 
a double mitral murmur. 

At autopsy the heart weighed fifteen ounces. There was a very great hyper- 
trophy, especially of the right ventricle, which was as thick as the left. All the 
cavities were much dilated. The most important valvular lesion was mitral 
stenosis, the orifice not admitting the end of the little finger. The valves were 
the seat of calcareous deposits. The curtains of the aortic valve were thickened 
and adherent; there was also thickening of the pulmonic and tricuspid valves. 



CIIRONIC VALVULAR DISEASE 500 

both in acute and chronic disease. Of 141 cases of valvular disease, in 
children under fourteen years, observed clinically, mitral murmurs were 
present in 135; in 131 the murmur of mitral insufficiency was heard, and 
in 99 this alone. In mitral insufficiency there is regurgitation of blood 
from the left ventricle into the left auricle during systole. There is 
heard a systolic murmur, synchronous with the apex impulse and with 
the first sound .of the heart, which may wholly or in part replace the first 
sound. It is loudest at the apex, transmitted to the left, and is usually 
heard at the inferior angle of the left scapula. In acute endocarditis the 
murmur is at first very soft and usually increases in intensity for sev- 
eral days. It may be represented by the syllables "whoo-ta" pronounced 
in a whisper. After attaining its maximum the murmur changes but 
little for some time. It may then diminish and eventually disappear 
entirely; but usually a murmur of moderate intensity remains. The 
only other important sign of acute endocarditis is enlargement of the 
heart which is almost entirely from dilatation. If the acute inflammation 
supervenes upon an old lesion, the previous murmur becomes louder and 
harsher. In chronic endocarditis the murmur is similar to that of acute 
endocarditis but generally louder and more widely diffused, and may be 
audible all over the chest. It is accompanied by an accentuation of the 
pulmonic second sound and by signs of hypertrophy, especially of the 
right heart. When both these signs are wanting, the existence of mitral 
insufficiency is somewhat doubtful, as a similar murmur may be func- 
tional or accidental. In the early stages of the disease and during com- 
pensation, the signs of hypertrophy predominate; in the later stages or 
with broken compensation, those of dilatation. 

Mitral stenosis is relatively uncommon. It occurs after repeated at- 
tacks of rheumatism, with a slowly progressing endocarditis. It is usu- 
ally associated with mitral regurgitation. With this lesion there is ob- 
struction to the flow of blood from the left auricle into the left ventricle 
It is mainly compensated for by hypertrophy of the right ventricle, but 
to a certain degree also by hypertrophy of the left auricle. The char- 
acteristic murmur of fully developed mitral stenosis is presystolic, pro- 
longed, rough in character, and terminates abruptly with a sharp first 
sound of the heart. It is loudest at or just above the apex, hut is audible 
over only a circumscribed area. Quite as constant and important for 
diagnosis is the presence of a '"purring thrill." which is very distinct 
upon palpation, and terminates sharply ae the apex strikes the chesl 
wall. This murmur is not common in children and is heard only in 
cases in which cardiac disease has lasted several years. 

With milder grades of mitral stenosis, or earlier in the course of the 
disease, there may be heard, shortly after the second Bound, ;i murmur 
softer in quality and of short duration. It i< usually audible above Bnd 



600 DISEASES OF THE CIRCULATORY SYSTEM 

to the inner side of the apex beat. In point of time this is often spoken 
of as the early diastolic murmur of mitral stenosis. It may be repre- 
sented by the whispered syllables "whoo-ta-whoo," in which the first syl- 
lable is the mitral systolic murmur, which is somewhat prolonged; the 
second syllable is the second cardiac sound; the last is the early diastolic 
murmur, which is much shorter than the systolic murmur. The pulse of 
mitral stenosis is usually small. 

Aortic lesions in children are much less common than mitral lesions, 
with which they are usually associated; they are seen in rather older 
patients. Aortic insufficiency is much more frequent than aortic stenosis. 
We have never seen it as the only lesion. It causes a regurgitation of 
blood from the aorta into the left ventricle during diastole. It is com- 
pensated for by dilatation and hypertrophy of the left ventricle. The 
signs of aortic insufficiency are a prolonged diastolic murmur, with or 
taking the place of the second sound of the heart, generally loudest at 
the left border of the sternum in the third space, and transmitted 
downward to the apex of the heart or the ensiform cartilage. This is 
invariably accompanied by signs of hypertrophy and dilatation of the 
left ventricle, which are usually marked. With great hypertrophy there 
is often bulging of the precordial area which may produce striking- 
thoracic deformity. A characteristic symptom is the intense throbbing 
of the carotids, with the sudden distention followed by a complete col- 
lapse of their walls, and the "water-hammer" pulse of Corrigan. A capil- 
lary pulse is often seen. 

Aortic stenosis, unless congenital, is very rare in early life, and almost 
never occurs as the only lesion. Aortic stenosis is compensated for by 
hypertrophy of the left ventricle. It causes a systolic murmur, which is 
usually loudest at the right border of the sternum in the second space, 
and is transmitted upward, being distinct in the carotids. The second 
sound is generally weak and may be replaced by a diastolic murmur. 
A systolic thrill over the aortic area is usually present. Without the 
signs of hypertrophy of the left ventricle, a positive diagnosis should 
not be made. 

Tricuspid insufficiency is usually secondary to disease of the left side 
of the heart, occurring in its late stages. It most frequently follows 
mitral insufficiency, when it is usually due to dilatation of the right 
ventricle without changes in the valves. It may be secondary to certain 
diseases of the lungs, such as emphysema, chronic interstitial pneumonia, 
or chronic pleurisy, and it may be due to congenital malformation. Tri- 
cuspid insufficiency gives a systolic murmur, loudest over the lower part 
of the sternum, but heard usually over a small area. It is associated with 
signs of dilatation of the right ventricle. The jugular veins stand out 
prominently, and often show systolic pulsation, especially upon the right 



• CHRONIC VALVULAR DISEASE 601 

side. There may be also systolic pulsation of the liver. The symptoms 
associated with tricuspid regurgitation are due to general systemic 
venous obstruction. 

Triscuspid stenosis, pulmonic stenosis, and pulmonic insufficiency are 
practically unknown in childhood except as congenital lesions. 

Prognosis, — The danger to life in acute endocarditis is not great un- 
less it is accompanied by pericarditis; but when both are present the 
outlook is serious. Of 115 fatal cases reported by Poynton; thirty-five 
proved fatal in the primary attack. It is difficult during the active stage 
to foretell how serious will be the resulting damage to the heart. It is 
only by watching the progress of a case that one can decide. As a rule 
the younger the child the worse the prognosis. 

Complete recovery from valvular disease is possible only when the 
lesions are very slight. Not many children die from chronic cardiac 
disease before reaching the age of eight or ten years. Up to about 
the time of puberty many children do very well ; then they begin to lose 
ground, and may fail rapidly. But more often it is a fresh endocarditis 
accompanying an intercurrent attack of rheumatism which marks the be- 
ginning of a downward course. The proportion of children who have 
serious cardiac lesions before the age of six years and reach adult life in 
good condition is very small. 

There are several features of cardiac disease in children, in conse- 
quence of which serious lesions tend to progress more rapidly than in 
adults. The muscular walls are less resistant, and hence dilatation oc- 
curs much more readily in childhood than in adult life. The heart must 
provide not only for constant needs, but for the growth of the body. If 
the patient's general nutrition is poor during the period of most rapid 
growth, this tells quickly and seriously upon the heart, and dilatation 
makes rapid progress. The demands made upon the heart at puberty 
are especially severe, by reason of the rapid growth of the body and 
the frequency with which anemia and malnutrition an* seen at this time. 
There is always present the danger of rapid advances in the disease 
from intercurrent attacks of rheumatism, from which children are more 
likely to suffer than are older subjects. Extensive pericardial adhesions 
are frequent, and seriously handicap the heart, greatly increasing the 
tendency to dilatation. The effect upon the heart of poor food, un- 
hygienic surroundings, and general malnutrition is much more marked 
than in adults. 

These unfavorable conditions are in pari offset by others in which 
the child has an advantage over the adult. Disease of the coronary 
arteries is very rare, and the valvular lesion which i< mosl frequently mel 
with — mitral insufficiency — is that which admit- of the moai complete 
compensation. 



602 DISEASES OF THE CIRCULATORY SYSTEM 

In making a prognosis in any given case, the amount of hypertrophy 
or dilatation which exists, and the presence or absence of pericardial ad- 
hesions are more important than the location or the special character of 
the murmur. The presence of valvular disease in childhood increases 
the danger from every acute disease, especially pertussis, diphtheria, 
pneumonia, and scarlet fever. The chances of recurring attacks of rheu- 
matism must also be taken into account. 

Probably the most important factor in the prognosis of chronic cardiac 
disease in childhood is the care and attention which the patient receives. 
While as a rule, if properly treated, these children do well among the 
well-to-do, they do very badly among the poor where suitable protection 
and treatment is impossible. 

Diagnosis. — Valvular disease is to be distinguished particularly from 
conditions in which there are heard functional or accidental murmurs. 
According to our experience the latter are very common even in young 
children. Mistakes usually arise from attaching too much importance 
to the presence of murmurs, and too little to the changes in the walls 
and cavities of the heart, with which valvular disease is almost invariably 
associated. It is not always possible to decide whether a murmur is 
organic or functional until the patient has been for some time under 
observation and treatment, particularly when anemia is present. The 
diagnostic points, so far as the murmurs are concerned, are mentioned 
in connection with accidental murmurs. 

Treatment. — The first and altogether the most important indication 
for every case of recent endocarditis is to secure for the heart as complete 
rest as possible, not only during the period of active inflammation, but 
for several succeeding weeks. The reason for this is that some dilatation 
is always present and this very readily increases. With children, proper 
rest can be secured only by keeping them in bed and in a recumbent posi- 
tion. The duration of the period of rest after mild attacks of endocarditis 
should be at least six weeks, and after severe attacks, three months. In 
these young patients changes in the walls of the heart take place very 
rapidly and the gravest consequences are liable to follow a neglect of these 
precautions. In old cases rest is indicated during every acute exacerba- 
tion; also whenever there is much dilatation and little hypertrophy, and 
whenever the signs of failing compensation are present. In these older 
cases rest is often impossible in the recumbent position ; if secured at 
all, it must be obtained with the child in the sitting posture or at least 
propped up with pillows. Whether much can be accomplished by the 
administration of anti-rheumatic remedies after endocarditis has de- 
veloped is very doubtful. Salicylates or aspirin and alkalis may be 
used unless they disturb the stomach. A child who is the subject of a 
chronic valvular disease should be constantly under a physician's observa- 



CHRONIC VALVULAR DISEASE 603 

tion. Irreparable harm often results from ignorant disregard of the 
simplest and most important rules of life for these patients. 

Several distinct conditions may be present which call for quite differ- 
ent management. The essential points may be stated in a few words: 
For all recent cases and during all exacerbations, rest, complete and pro- 
longed; for deformed valves with good heart walls and perfect compen- 
sation, fresh air, moderate exercise, and general tonics; for feeble heart 
walls, failing compensation and dilatation, rest and cardiac tonics. 

During the stage of compensation, treatment directed especially to 
the heart is rarely necessary. The main purpose should be to maintain 
the patient's general nutrition at the highest possible point during the 
period of active growth. At the very least the patient should be carefully 
examined three or four times each year, in order that the physician may 
note the progress of the disease, and be able to direct the child's educa- 
tion, occupation, exercise, and surroundings so as to meet, as far as 
possible, the changing conditions. To this end, diet, sleep, study, and 
exercise should receive the most careful attention. If malnutrition and 
anemia are allowed to go on unchecked until they become severe, the 
cardiac disease may make rapid strides, and as much harm be done in a 
few months as otherwise might not occur in years. The question of ex- 
ercise and recreation is always a difficult one to settle. Often too little 
latitude is given, and the heart, like the voluntary muscles, loses its tone. 
Every form of exercise requiring a prolonged severe strain should be 
forbidden, particularly swimming and competitive games, like ball and 
tennis, and others requiring much running; but skating, rowing, horse- 
back exercise, regulated gymnastics, and cycling on the level — all in 
moderation — may be allowed not only without harm, but with positive 
benefit; but any of these, used immoderately, may be productive of 
great injury. All exercise should be taken with regularity and system, 
the amount being carefully measured by the child's condition, and 
increased freedom allowed only after watching the effect. If the patient 
is a boy who must earn his own living, the physician should see to it 
that the occupation chosen is not one likely to make special demands 
upon the heart or to expose him unduly to conditions likely to induce 
rheumatism. 

Special watchfulness is required at the time of puberty to prevent 
overpressure in schools, and the development of anemia. The firsi symp- 
toms of these conditions should be treated energetically, and if the heart 
seems to be overtaxed the child should be put to bed. These who are 
specially liable to rheumatic attacks should, if possible, spend the winter 
and spring months in a warm, dry climate. 

In the stage of failing compensation, the game genera] conditions are 
present as in adults, and they are to be managed in pretty much the same 



604 DISEASES OF THE CIRCULATORY SYSTEM 

way. When such symptoms are first seen, prolonged rest in bed should 
be insisted upon as the thing most likely to restore the normal conditions. 
Digitalis and strophanthus are useful in children with about the same 
indications as in adults, viz., dilatation, dropsy, low arterial tension, and 
weak pulse. They may be used in doses of from five to ten drops of the 
tincture every four to six hours for a child of ten years. If there is 
much dilatation of the right side of the heart the same treatment is 
indicated as described in pericarditis. One should be cautious about 
using digitalis for an irregular and overacting heart, opium being de- 
cidedly preferable under these conditions. An overloaded venous circula- 
tion may be relieved by diuretics, by saline purgatives, or even by 
venesection. Iron and tonics generally are indicated, particularly strych- 
nin and cod-liver oil. 



MALIGNANT ENDOCARDITIS 

Malignant or ulcerative endocarditis is rare in childhood. Among 
the youngest cases reported are one by Bond in an infant of two and 
a half months, and one by Harris in a boy four years old. In Bond's 
case the mitral valve was affected. The infection was with the B. pyo- 
cyaneus. In Harris' case the right side of the heart was affected and the 
lesion was secondary to a congenital malformation. We have seen endo- 
carditis of the mitral valve in an infant of six months following a septic 
arthritis of the knee. Of the cases reported in early life, most have been 
in children over ten years of age. Malignant endocarditis is never pri- 
mary. It may be seen in any infectious disease or septic process. In sev- 
enty-five per cent of the cases it is ingrafted upon a previous valvular dis- 
ease. In the series of collected cases of congenital malformations of the 
heart, there were four deaths from malignant endocarditis, all but one, 
however, occurring in adult life. The bacteria most frequently concerned 
are the staphylococcus or streptococcus, next the pneumococcus, and 
rarely the gonococcus, the influenza or the pyocyaneus bacillus. 

Malignant endocarditis presents a great variety of symptoms, often 
making the diagnosis extremely difficult. There is generally a remittent 
type of fever, sometimes repeated rigors, sweating, low delirium, stupor 
or coma, and extreme prostration. There is often a fine petechial erup- 
tion. Usually there is a cardiac murmur, the location of which depends 
upon the seat of the disease ; it is most frequently the murmur of mitral 
regurgitation. It is sometimes faint, and may be absent. From the 
emboli there may result hemiplegia, rapid swelling of the spleen, bloody 
urine or pneumonia. The disease lasts from three weeks to three months, 
death being the almost invariable termination. The most characteristic 



MYOCARDITIS CO.", 

features of malignant endocarditis are the development of pyemic or 
typhoid symptoms with a petechial eruption, in a patient who lias pre- 
viously had valvular disease. Blood cultures in most cases give positive 
results, though not always early in the disease. 

The treatment is symptomatic. The use of vaccines has not met 
expectations; in the most acute cases no benefit has followed their ad- 
ministration, and even in the more prolonged types it is very doubtful 
if they have any value. 

MYOCARDITIS 

Disease of the muscular wall of the heart is rare in children, and of 
comparatively little importance, except in connection with acute endo- 
and pericarditis and the acute infectious diseases. It is almost invariably 
secondary to some infectious process. Aside from the rheumatic condi- 
tions already considered the diseases which furnish most of the cases are 
scarlet fever and diphtheria. The most important local cause is peri- 
carditis with adhesions. 

Lesions. — In extra-uterine life, myocarditis as a rule affects chiefly 
the wall of the left ventricle, the papillary muscles, or the septum, but 
the entire organ is involved. The heart is of a grayish or yellowish-red, 
sometimes mottled color, very soft, friable, and flabby, and there is fre- 
quently dilatation of the cavities. 

Two varieties of myocarditis are described, the parenchymatous and 
the interstitial. In the parenchymatous form there is a degeneratioD of 
the muscle fiber which, according to Romberg, is most frequently al- 
buminous, next fatty, and least frequently hyaline. There is a loss of 
the transverse striatums, and there may be complete disintegration of 
the fibers. This process may be circumscribed, but it is usually diffuse. 
In the interstitial form the lesion usually occurs in small, circumscribed 
areas. There is an infiltration of round cells, chiefly mononuclear, be- 
tween the muscular fibers of the heart. The process, when acute, may 
result in absorption or in the production of small abscesses. In chronic 
cases it may lead to the formation of areas of dense connective tissue 
resembling cicatrices, in the heart wall. Either the interstitial or the 
parenchymatous form may occur alone, hut in most of the acute i 
they are combined. In addition, there is usually some degree of mural 
endocarditis and inflammation of the pericardium next to the heart wall. 
Dilatation frequently follows. Cardiac aneurism and even rupture have 
been known to occur in a child of six years (Hadden'fl case). 

Symptoms. — In many cases in which advanced lesions have \»'i'\] 
found at autopsy there have been no symptoms appreciated during life. 
Careful examination of the heart, however, will usually show an altera- 
21 



606 DISEASES OF THE CIRCULATORY SYSTEM 

tion in the first cardiac sound, the muscular quality diminishing and 
the valvular quality increasing. This may go on even to a total disap- 
pearance of the muscular quality and only a flapping valvular sound may 
remain. The first and the second sounds are then almost alike. In such 
severe cases diastole is relatively short and the rhythm is much like that 
of fetal life. A systolic murmur due to dilatation of the auriculoven- 
tricular ring, or to imperfect action of the papillary muscles, may be 
heard at the apex. The heart is usually slightly dilated, but may be 
excessively so. Its action is generally increased in rapidity and may be 
irregular; a slow heart, 50 to 70, with feeble, valvular sounds is less 
frequent but very characteristic. The apex beat is diminished in intensity 
and the pulse is soft and weak. The blood pressure is low, frequently 
60 mm. or even less. Other symptoms may be present that are dependent 
upon feeble heart action — pallor, dyspnea, slight cyanosis, and attacks 
of syncope? Less frequently there may be dropsy of the feet or the serous 
cavities, and scanty urine sometimes containing albumin. Death may 
occur suddenly from cardiac paralysis or gradually from circulatory fail- 
ure. Eecovery may take place after alarming symptoms have been 
present, these slowly abating. It may be many weeks before the normal 
cardiac sounds are heard. 

Treatment. — This is mainly symptomatic. After severe attacks of 
those infectious diseases in which myocardi+is is liable to occur, and at 
any time when it is suspected, patients should be kept recumbent for 
several weeks, and special care exercised to prevent any sudden exertion, 
as death has resulted from so slight a thing as suddenly sitting up in 
bed. Once definite symptoms have developed, absolute rest is imperative. 
Much more is to be expected from complete rest than from drugs, which 
as often employed may do positive harm. Digitalis should be used with 
caution, and never in large doses. In some cases with symptoms indicat- 
ing imminent heart failure rather striking benefit has followed the use 
of morphin hypodermically. 



ACCIDENTAL MURMURS 

Under this term are included those murmurs that do not depend 
upon organic change in the heart or are not functional in the sense that 
actual regurgitation takes place through a dilated orifice. 

In early life such murmurs are exceedingly common. Our own ob- 
servations confirm those published by ITamill and others, that murmurs 
may be heard on careful examination in nearly fifty per cent of nil 
children^ Their existence is often a cause of much needless anxiety 
and of many unnecessary restrictions of a child's activities. The^ are 



ACCIDENTAL MURMURS 607 

almost invariably systolic in time ; they are usually of moderate intensity, 
soft and blowing in character, and are not transmitted. They are unac- 
companied by changes in the size of the heart or by symptoms referable 
to its function. They are apt to be inconstant in occurrence, and often 
change in character or disappear altogether by changing the posture of 
the child. 

The exact method of their production is still a matter of doubt. 
In certain instances they are apparently dependent upon changes in the 
blood occurring in anemia. In several of our patients, infants with 
grave anemia, quite loud murmurs have disappeared after transfusion. 
In other cases there can be no doubt that the murmurs are produced 
in the lungs, air being forced through the bronchi by the movements of 
the contracting heart. The term cardiopulmonary is applicable to mur- 
murs of this origin. This murmur is not loud, is never heard to the 
right of the sternum and disappears when the breath is held. It is 
usually loudest over the pulmonary artery, intensified by excitement or 
exertion, and often disappears when changing from a standing to a 
supine position. 

Atonic murmurs are probably due to lack of tone in the cardiac 
muscle leading to a real but temporary insufficiency, usually at the mitral 
orifice. These murmurs correspond in most cases to a slight mitral 
regurgitant murmur. They are heard in the course of a number of 
acute febrile diseases — notably scarlet and typhoid fevers; also in many 
pale, delicate, nervous children, especially between the ages of eight and 
fourteen years. 

Anemic murmurs are usually accompanied by a venous hum. but not 
by an accentuated pulmonic second sound. Other causes of accidental 
murmurs such as a functional stenosis of the pulmonary artery and 
infundibulum, functional mitral insufficiency and eddy currents within 
the ventricles are not so well substantiated by clinical or experimental 
proof. 

Probably the most frequent of all accidental murmurs is the soft 
systolic murmur which is heard over the body of the heart near the left- 
border of the sternum at about the nipple level; it is increased by placing 
the child on his back and in many patients is heard only in this posit ion. 
This murmur is usually intensified by overact ion of the heart whether 
due to excitement, exertion or fever. It is accompanied by no symptoms 
referable to the heart or circulation and it may he mel with in children 
who are in perfect health. This murmur is more often heard in infants 
and young children, but may he present for many years. It is often 
confused with murmurs due to cardiac malformation, but it is not loud 
as are they, and is heard only over a localized area, 

The differentiation from murmurs due to organic cardiac di 



608 DISEASES OF THE CIRCULATORY SYSTEM 

may be difficult and only possible by continuous observation for some 
time ; but in any infant or child one should hesitate to make a diagnosis 
of congenital or acquired organic disease from the mere presence of a 
soft systolic murmur. 



FUNCTIONAL DISTURBANCES OF THE HEART 

Disturbances of the heart's action unconnected with organic disease 
are quite common in children, especially from the seventh or eighth 
year up to puberty. Common causes are disorders of digestion, the 
excessive use of tea, coffee or tobacco, especially in the form of cigarette 
smoking, anemia, over pressure in schools or other conditions leading 
to nervous exhaustion. The exciting cause is sometimes a great emo- 
tional disturbance such as fright or excitement, or it may follow any 
serious acute illness. As a rule there are more subjective symptoms with 
functional than with organic disease unless the latter is advanced. Func- 
tional disturbance may take the form of attacks of palpitation, tachy- 
cardia, bradycardia or arrhythmia. 

With attacks of palpitation there may be a sense of oppression in 
the precordium ; there may be some dyspnea or even orthopnea ; the pulse 
is generally rapid, often slightly irregular. There is strong pulsation 
of the carotids and sometimes headache or vertigo. There may be cold 
extremities and general perspiration. The duration of the attack is 
from a few minutes to several hours. The treatment is that of the 
general nervous condition upon which the palpitation depends. 

Tachycardia (rapid heart) occurs in certain susceptible children 
from slight cause, most frequently when the general health is below par, 
in conditions of anemia, and in nervous children — particularly girls 
about the time of puberty. 

In the same patient the symptoms may occur at intervals for years. 
The pulse at such times may be from 120 to 1G0 per minute or even 
more rapid than this. The condition may persist for days or weeks at 
a time, then subsiding, but the symptoms recurring at variable intervals. 
In some children a very rapid pulse must be considered an idiosyncrasy. 

In a patient with an attack of tachycardia position makes little 
difference with the heart rate. Sometimes it is even more rapid when 
the child is recumbent. It is, however, almost invariably much lower 
during sleep and at such time may even be quite normal. The rhythm 
of the heart is not disturbed. It is important not to confound this 
condition with Graves' disease. The treatment is to be addressed to the 
nervous condition present, to which as a rule the cardiac symptom is 
secondary, 



FUNCTIONAL DISTURBANCES OF THE HEART 609 

In certain children there is seen a more rare but severe form of 
this condition known as paroxysmal tachycardia. It has been observed 
in children as young as three years. There develops abruptly and with- 
out assignable cause an extraordinary heart rate which may be 200 to 250 
per minute. Such attacks may last from a few minutes to several weeks, 
both beginning and ending abruptly. After an attack the pulse may for 
a time be abnormally slow. In prolonged cases some cardiac dilatation 
often occurs, and a systolic murmur may develop. Serious consequences 
may follow, such as swelling of the liver, dropsy, etc. The cause and 
mechanism of such an abnormal cardiac stimulus are as yet obscure. 
Curiously, attacks may often be cut short by vomiting. The indications 
for treatment are nervous sedatives, complete rest and prolonged treat- 
ment with digitalis in full doses. 

Bradycardia (slow heart) is a much less frequent condition than 
tachycardia. It is seen in a variety of pathological conditions not involv- 
ing the heart, such as jaundice, certain poisons, etc. Its persistence in 
young children is always a suspicious symptom suggesting cerebral dis- 
ease, though in some children an abnormally slow pulse is an idiosyn- 
crasy. Existing by itself, no importance is to be attached to it as a sign 
of cardiac disease. 

Arrhythmia. — Like all other nervous adjustments the heart-regulat- 
ing mechanism does not work with the same uniformity in children as 
in older subjects. In consequence of this, disturbances of cardiac rhythm 
are more frequently seen and occur from slighter causes in early life than 
later. Cardiac irregularity is exceedingly common in children, and Is 
often seen in those who are apparently in excellent health. Of 321 
unselected children studied by Friberger only 37 per cent had a fairly 
regular pulse, while over 12 per cent had a very irregular pulse. A 
certain degree of cardiac irregularity up to the time of puberty is so 
common that it must almost be regarded as the rule. Only exceptionally 
does it indicate disease of the heart; particularly is this the case when it 
occurs with slow heart action. The higher forms of irregularity are 
usually seen in younger children. In general, it is more often observed 
in girls, but is not affected by general development nor by cardiac weak- 
ness. It is slightly more frequent in nervous subjects. 

Sinus arrhythmia, reflex arrhythmia or. as it is sometimes railed, 
vagus irregularity, is the characteristic type of arrhythmia in early life. 
The alteration in cardiac rhythm is brought about by stimuli which a 
outside of the heart and reach it by one of the cardiac oerves. Tin- point 
of origin of the impulse is probably the sinus region. Reflex stimuli arc 
constantly reaching the heart. The regulation of beats is usually bo 
perfect, however, that they do not influence its rate, [f the resistance 
to outside stimuli is less than normal these stimuli may reflexly affect 



610 DISEASES OF THE CIRCULATORY SYSTEM 

the rate. It has been shown by Einthoven and others that stimuli pass 
up the vagus nerves with each respiration. The nervous control of the 
various functions of the body is imperfectly developed in children and 
sinus arrhythmia is in them a frequent finding. It bears, in many in- 
stances, a close relationship to the respiration. The irregularity is 
generally but not always shown in the pulse at the wrist. It is best 
determined by auscultation. The irregularity is often rhythmical, vary- 
ing with the respiration. With inspiration, the action of the heart be- 
comes rapid and with expiration slow. Other varieties are, irregular 
pauses or a sudden retardation of frequency at irregular intervals. 

There are no subjective symptoms and the patient is seldom con- 
scious of the condition. The arrhythmia is present during sleep, often 
most marked at that time and associated with irregular respiration. A 
diagnosis of sinus arrhythmia is made chiefly by its association with 
respiration; it disappears with rapid respiration or when the breath is 
held. It is also characteristic of this condition that it is seen only with 
a slow heart action, disappearing at once when the heart's action from 
any cause becomes rapid. 

This form of irregularity is not in itself significant. It is not a 
symptom of cardiac disease, nor does it aifect the patient's health or his 
development. It may safely be ignored altogether. In certain children, 
however, it may be a constant phenomenon and may persist for many 
3^ears. Sinus arrhythmia may be met with as a temporary condition 
after any severe acute illness; it may be seen in children of the neuras- 
thenic type associated with other evidences of nervous instability: In 
many cases, even of the most pronounced type, no adequate cause can 
be discovered. 

Another type of irregularity is clue to the production of extra systoles. 
These are occasional, irregular beats caused by single abnormal stimuli, 
arising within the heart, either in the auricle or ventricle. Extra systoles 
are seldom observed in young children, — more frequently in those over 
eight or ten years old. The extra systoles may be followed by a long 
pause the following normal beat being omitted, or two beats may occur 
very close together. Extra systoles are usually not sufficiently forcible 
to open the aortic valves. For this reason they cannot often be felt at 
the wrist but may, in thin subjects, be recognized by palpation and they 
can be determined by auscultation or tracings. There may be no sub- 
jective symptoms or there may be complaint of precordial anxiety and 
unrest when the extra systoles occur. This form of irregularity is seldom 
a constant phenomenon, but with susceptible persons it comes and goes 
from apparently slight causes. It is most marked when the pulse is slow 
and may disappear when it becomes rapid, sometimes also on assuming 
a recumbent position. 



DISEASES OF THE BLOOD-VESSELS (ill 

Extra systoles are usually not associated with other sigus or symptoms 
of cardiac disease in children and under such circumstances may be 
practically ignored. The condition is not a serious one. Its causes may 
be disorders of the stomach, an extremely sensitive nervous system, or 
convalescence from an acute febrile disease, especially pneumonia. The 
treatment should be addressed to the general condition, not to the heart. 
Exercise need not be restricted. 



DISEASES OF THE BLOOD-VESSELS 

Coarctation of the Arch of the Aorta. — This is a rare congenital lesion 
in which there is a partial or complete occlusion of the aorta at or near 
the junction with the ductus arteriosus. The ductus may remain patent 
and the systemic circulation be carried on almost exclusively by means of 
the blood which passes by way of the ductus from the pulmonary artery 
to the aorta below the constriction. Coarctation of the arch may be the 
only lesion or there may be associated lesions with death in the first few 
months. When the stenosis is beyond the opening of the ductus arterio- 
sus a very complete collateral circulation develops chiefly by means of the 
superior intercostals and mammary arteries above, and the aortic inter- 
costals and superficial and deep epigastric arteries below. In consequence 
of this there may be no symptoms of the condition. Instances are on 
record where persons with this lesion have lived to advanced age, but 
often they are stunted in growth, poorly nourished, and complain of 
dyspnea. 

The physical signs are at times very characteristic. The collateral 
circulation may show superficially over the thorax and upper abdomen. 
A marked disproportion in intensity between the radial pulse and the 
femoral pulse may be present. There is frequently marked pulsation 
and a thrill in the suprasternal notch owing to dilatation of the arch of 
the aorta. A loud systolic murmur may be heard in the second or third 
spaces on the left side, well out from the sternum. Death may be due 
to intercurrent disease, to failing circulation and sometimes to rupture 
of the heart or of the arch of the aorta. 

Abnormally Small Arteries (Arterial hypoplasia). — This condition is 
not a common one. The only thing which is abnormal in the cir- 
culatory system may be that the aorta, and sometimes nil tin- large 
vessels are only two-thirds or three-fourths their usual caliber, or 
even less. This may interfere seriously with the growth and de- 
velopment of the body, especially of the genital organs, although this re- 
sult is not a constant one. The condition is found occasionally in cases of 
chlorosis. There is sometimes associated ;i certain amount of hypertrophy 
of the heart. The other symptoms are anemia, and sometimes an imperfect 



612 DISEASES OF THE CIRCULATORY SYSTEM 

development of the body. A positive diagnosis during life is impossible. 

Aneurism and Atheroma. — In early life chronic disease of the blood- 
vessels is exceedingly rare, yet a sufficient number of observations have 
been recorded to show that even young children are not exempt from this 
form of disease. Sanne records the youngest case, which occurred in a 
fetus born at about the eighth month, in whose body there was found a 
large aneurism of the abdominal aorta just below the origin of the renal 
arteries. Le Boutillier has collected seven cases of thoracic aneurism in 
children under ten years ; the arch of the aorta was the usual seat. 

Probably, the most important etiological factor, as in adult life, is 
syphilis, but in only a few of the cases reported was the evidence of 
syphilis conclusive. In two cases there was general tuberculosis. In at 
least two cases whooping-cough appeared to act as a contributing cause. 
Aneurism may also be due to some local condition, such as an erosion 
from a bony growth, an abscess in the neighborhood, or to embolism. 
The symptoms and course of aneurism in young children do not differ 
essentially from those of the disease as seen in adults. 

In addition to the cases of aneurism referred to above, we have found 
reports of seven cases of atheroma in very young subjects. In Sanne's 
case the patient was but two years old, and patches of atheromatous de- 
generation were found in several places in the aorta. In Hawkins' case, 
eleven years old, there was found extensive atheromatous disease of the 
aorta, subclavian and carotid arteries. In Filatow's case, atheromatous 
degeneration affected the arteries at the base of the brain, causing death 
from cerebral hemorrhage. It is interesting to note that in this patient, 
who was only eleven years old, there was also present chronic diffuse 
nephritis with contracted kidneys. A similar condition of the kidneys 
and arteries was observed by Dickinson in a girl of six years. We have 
seen extensive arterio-sclerosis the result of hereditary syphilis in a boy 
of five. Death occurred from hemorrhage into the lateral ventricle. 

Embolism and Thrombosis. — Embolism is very rare in early life, even 
with acute endocarditis. The emboli are usually swept into the circu- 
lation from vegetations upon the valves of the heart. The symptoms 
which they produce will depend upon the nature of the emboli and the 
vessels occluded by them. If they lodge in the brain they may cause 
paralysis or convulsions: if in the spleen, pain and swelling of this 
organ; if in the kidneys, pain, tenderness, and sometimes hematuria; 
if in the lungs, cough, sometimes accompanied by hemoptysis and occa- 
sionally by a sharp thoracic pain. If the emboli are infectious, they 
may give rise to abscesses. The pathological results following embolism 
are similar to those which are seen in adults. 

The most frequent form of thrombosis, that occurring in the sinuses 
of the brain, is discussed in connection with Diseases of the Nervous 



DISEASES OF THE BLOOD-VESSELS 613 

System. Cardiac thrombi, especially of the right side of the heart, are 
not infrequently found in patients dying from cardiac disease, pneumonia, 
and occasionally also from other acute inflammatory processes and acute 
infectious diseases, particularly diphtheria. These thrombi are in most 
cases produced during the last few hours of life, or just at the time of 
death, and are of no clinical importance. They frequently extend from 
the heart into the large blood-vessels, particularly the pulmonary artery. 
Thrombosis occasionally occurs in any of the large vascular trunks in 
childhood as well as in adult life. 

Thrombosis of the Internal Jugular Vein. — M. Pasteur has reported 
a case in a child two and a half years old, in which the middle of the 
vein was filled with an organized thrombus, and the lower portion ob- 
literated and reduced to a fibrous cord. The symptoms were swelling. 
edema, and cyanosis of the face, and dilatation of the facial vein, but 
not of the external jugular. There were clubbing of the fingers and 
edema of the feet, but not of the arms. The heart was dilated and 
hypertrophied, but there was no valvular disease. The symptoms had 
existed since an attack of pneumonia, eighteen months before death. 

Thrombosis of the Vena Cava. — Quite a number of cases are on 
record where this has occurred as the result of pressure from large 
abdominal tumors; it has followed new growths of the kidney and large 
masses of tuberculous lymph nodes. Xeurutter and Salmon have re- 
corded a case of thrombosis, apparently of marantic origin, in a child 
seven years old. The thrombus filled the vena cava, and extended to the 
origin of the hepatic veins and into both femorals. Death occurred from 
tuberculosis. In Scudder's case (seventeen years old) there was appar- 
ently obliteration (probably congenital) of the inferior vena cava; there 
was an extensive varicose condition of all the abdominal veins. The 
symptoms of thrombosis of the vena cava are swelling and edema of the 
feet — sometimes of the abdominal walls and the groin — and very great 
dilatation of the superficial abdominal vein-. 

TJtrombosis of the Aorta. — A case has been reported by Leopold in 
a newly-born child who was delivered by version. The thrombus was 
of recent origin, and filled the lower aorta, extending into the femoral 
artery. A case of thrombosis of the aorta occurring in a girl of thir- 
teen years has been reported by Wallis. The aorta was very narrow, and 
probably the seat of syphilitic disease. The thrombus extended from the 
origin of the renal arteries to the celiac axis. 

Thrombosis in Infections Diseases. — There is occasionally ><-*-\\ in 
typhoid fever, but more frequently in diphtheria, thrombosis "f some of 
the large venous trunks, usually of one of the lower extremities. The 
symptoms are pain, localized swelling, ami partial paralysis. If the 
artery is affected, there may be gangrene. 



SECTIOX VI 
DISEASES OF THE UROGENITAL SYSTEM 

CHAPTER I 
THE URINE IN INFANCY AND CHILDHOOD 

While a study of the urine is of much less importance in early life 
than of the symptoms referable, either to the digestive or respiratory 
system, it is deserving of much more attention than it has generally re- 
ceived. In infancy especially it is attended with some difficulty, owing 
to the fact that it is by no means an easy matter to secure readily speci- 
mens for examination. 

Methods of Collecting Urine. — In male infants this may be done by 
placing the penis in the neck of a small bottle or test tube which lies 
between the thighs, and is secured in position by pieces of tape passing 
over the hips and beneath the perineum. The urine of female infants can 
sometimes be collected in a similar May by placing a small cup or a large- 
mouthed bottle over the vulva and holding it in place by the napkin or 
by pieces of adhesive plaster. A plan often successful is to put the infant 
upon a chamber after a long sleep. It should be done at the instant of 
waking or the child may be wakened for the purpose. When an infant 
has not voided for one or two hours the application of a cold hand or a 
cloth wrung out of ice water to the abdomen or the buttocks will usually 
cause emptying of the bladder. A small amount of urine, sufficient to 
test for albumin, may often be obtained by placing absorbent cotton over 
the vulva or penis. The most certain of all means, however, is catheter- 
ization, which, however, should not be resorted to unless absolutely m 
sary. A soft-rubber catheter, size 6 or 7, American scale (!> or 1 1 
French), should be used for infants. 

Daily Quantity. — This is relatively much larger in infants than in 
older children and in adults, on account of the large amount of water 
taken with the food. The quantity fluctuates widely from day to day, 
according to the amount of fluid food taken and the activity of the skin 
and bowels. The figures following art' the averages obtained by com- 
bining the results of the investigations of Schabanowa, Cruse, Camerer, 
Pollak, Martin-Ruge, Berti, Setoff, and Ilcrter. 

615 



616 



DISEASES OF THE UROGENITAL SYSTEM 

Average Daily Quantity of Urine in Health 



Age. 



Grams. 



Ounces. 



First twenty-four hours . . . 
Second twenty-four hours . 

Three to six days 

Seven days to two months 

Two to six months 

Six months to two years. . 

Two to five years 

Five to eight years 

Eight to fourteen years . . . 



Oto 


60 


Oto 2 


10 " 


90 


H " 3 


90 " 


250 


3 " 8 


150 " 


400 


5 " 13 


210 " 


500 


7 " 16 


250 " 


600 


8 " 20 


500 " 


800 


16 " 26 


600 " 


1,200 


20 " 40 


1,000 " 


1,500 


32 " 48 



Frequency of Micturition. — This is greatest in young infants, and 
diminishes steadily as age advances. In infancy, during the waking 
hours, the urine is passed very frequently, often two or three times an 
hour, while during sleep it is retained from two to six hours. By the 
third year the urine may be held during sleep for eight or nine hours, 
and at other times for two or three hours. Such control of the sphinc- 
ter of the bladder is often obtained at two years, and sometimes even at 
an earlier period. From slight nervous disturbances or minor ailments 
of any kind, this control is impaired, and the urine may be passed by 
children of four or five years with the frequency seen in infants. 

Physical Character and Composition. — The urine of the newly born 
is usually highly colored. During later infancy it is pale and frequently 
turbid, even when practically normal, owing to the presence of mucus; 
this turbidity often no amount of nitration will entirely remove. Less 
frequently the turbidity depends upon urates. The urine of the first 
few days of life often shows a deposit of urates ov uric acid in the form 
of a pink or reddish-yellow stain upon the napkin. The reaction of the 
urine at this time is usually strongly acid, but throughout the rest of 
infancy it is faintly acid or neutral. 

The specific gravity is higher during the first two days than at any 
time in infancy on account of the scanty supply of fluid taken; it is 
usually lowest from the third to the sixth day, but from this time it rises 
steadily until puberty is reached. The specific gravity varies with the 
quantity. From the writers already referred to, the following figures 
are taken: 

Specific gravity. 

First to third day 1.010 to 1.012 

Fourth to tenth day 1 .004 " 1 .008 

Tenth day to sixth month 1 .004 " 1 .010 

Six months to two years 1 .006 " 1 .012 

Two to eight years 1 .008 " 1 .016 

Eight to fourteen years . . 1 .012 " 1 .020 

Microscopically, the urine of the newly born shows the presence of 
many squamous epithelial cells, mucus, granular matter, crystals of uric 



LORDOTIC, ORTHOSTATIC OR CYCLIC ALBUMINURIA 617 

acid and amorphous or crystalline urates and amorphous bilirubin crystals 
which are insoluble in urine not containing bile acids. It is not uncom- 
mon to find hyaline and even granular casts. Martin-Ruge found hyaline 
casts in the urine of fourteen out of twenty-four healthy nursing infant- 
examined during the first week. Granular casts were much less frequent. 

The inorganic salts (phosphates, chlorids, sulphates) arc all present 
in the urine of the newly born, but in relatively small quantities, in- 
creasing as age advances. The coloring matters are also less abundant. 

Albumin is often present in the urine during the first days, but 
usually in small amount. Cruse found it twenty-eight times in ninety 
observations upon healthy infants; usually the quantity was small, 
amounting to traces only, but in two cases it was quite large upon the 
second day. These observations are confirmed by the investigations of 
Martin-Ruge, and also of Pollak. 

Sugar is frequently found in the urine of healthy infants during the 
first two months. It may be made to appear in the urine of healthy 
infants by simply increasing the quantity ingested. The different sugars 
vary as regards the amount which can be taken before it is thus elim- 
inated. According to Grosz, lactose appears if the quantity is increased 
to three or four grams per kilo, of body weight; glucose, only when 
five grams, and maltose^ not until seven and seven-tenths grams per kilo. 



LORDOTIC, ORTHOSTATIC OR CYCLIC ALBUMINURIA 

This condition, although uncommon in young children, is frequently 
seen between the ages of six and fifteen years. It is much more common 
in males than in females. A recurrent but benign albuminuria in chil- 
dren has been recognized for many years and has been referred to numer- 
ous causes such as cold bathing, fatigue following muscular exertion, 
dyspeptic conditions or a diet rich in nitrogenous food. It is doubtful if 
any of these are of etiological importance, for the condition persists when 
their influence is entirely eliminated. The most important factor is 
undoubtedly a mechanical one. The albuminuria is due to the upright 
position. When this is not assumed there is no albuminuria, or the 
merest trace. There can also be no doubt that lordosis playa .1 very 
important part, if not the most important part. The majority of cases 
occur in children with a considerable degree of lordosis. H<>w this acts. 
by producing congestion of the kidney by pressure on the vessels at the 
pelvis or otherwise is not quite clear. 

Symptoms. — Some of the patients exhibiting orthostatic albuminuria 
are well nourished and have no other Bigns of disease; the majority, 
however, while they may he considered healthy, are not vigorous. They 



618 DISEASES OF THE UROGENITAL SYSTEM 

are usually anemic and rather poorly nourished. They suffer from 
gastro-intestinal symptoms of which constipation is a frequent one and 
often have headaches and various neuroses. Cardiac palpitation and 
vasomotor symptoms are common. The trunk is usually long in pro- 
portion to the height and a degree of lordosis is the rule. The abdomen' 
is usually prominent. Sometimes symptoms of angioneurotic edema 
have directed attention to the urine. Except for these there are no 
symptoms that would direct attention to the genito-urinary tract and 
the condition is usually discovered in an attempt to explain the poor 
general condition of the patient. 

The urine is usually clear and that which is secreted while the child 
is lying down presents nothing abnormal. Shortly after assuming the 
upright position albumin appears in greater or less quantity. This is 
serum albumin plus a substance which is precipitated by acetic acid in 
the cold. Eecent studies have shown that this is probably chondroitin 
sulphuric acid united with serum albumin. The amount of albumin 
present may vary from a trace to 50 per cent by volume or even more. 
The substance precipitated by acetic acid is never in large quantity. It 
causes clouding of the urine or an appreciable precipitate but no more. 
It is sometimes found alone and always when serum albumin is present. 
The assumption of a markedly lordotic position increases greatly the 
amount of albuminuria. Infrequently casts may be present; they are 
usually hyaline casts and few in number. They may occasionally be 
associated with a temporary glycosuria but the kidney does not show a 
greater permeability to other substances used for renal tests. Evidences 
of nephritis, high arterial tension, cardiac hypertrophy, etc., are absent. 

Orthostatic albuminuria is not a dangerous condition, nor does it 
interfere with health. It disappears usually at or shortly after puberty. 
Occasionally it may persist well on into adult life. 

It is important that orthostatic albuminuria should not be confused 
with nephritis. Children are not infrequently confined to bed for a long 
time and placed upon a rigid diet with the mistaken idea that nephritis 
is present. If, after repeated examinations, it is found that albumin is 
present only when the upright or lordotic position is assumed, if a sub- 
stance precipitable by acetic acid in the cold is present and other evi- 
dences of nephritis absent, the diagnosis of orthostatic albuminuria may 
properly be made. 

Treatment. — If lordosis is present, as is usually the case, much can 
be done to prevent the albuminuria. The abdominal muscles should be 
strengthened by appropriate gymnastic exercises. The children should 
practice assuming and maintaining a proper position in standing and 
sitting. Exercise is of value but prolonged standing should be avoided. 
If the lordosis persists in spite of these measures a light form of appara- 



HEMOGLOBINURIA 619 

tus may be worn which prevents the lordotic position but does not inter- 
fere with exercise. Associated conditions such as anemia, constipation, 
and the various neuroses should receive their appropriate treatment. 



HEMATURIA 

Hematuria is characterized by the presence of red blood-cells in the 
urine, and is to be distinguished from hemoglobinuria where only blood 
pigment is present. 

Hematuria may result from local or general causes. In infancy it 
may be due to new growths of the kidney. Such hemorrhages, though 
rare, may be abundant, and may be seen early. Hematuria may occur 
also as a symptom of acute nephritis, especially that complicating scarlet 
fever, or it may result from the irritation of a calculus in the kidney, the 
ureter, or the bladder. In rare instances its cause is a new growth of 
the bladder, and it may be due to traumatism. It may sometimes be 
produced by the irritation of a highly concentrated urine, owing to the 
fact that too little fluid is taken. We once saw a marked example of this 
in an infant eight months old, when no other explanation could be found. 
Hematuria is occasionally seen following uric-acid infarctions in the 
newly born. It may also occur at this age as one of the symptoms of 
sepsis. Among the general causes the most important are, the hemor- 
rhagic disease of the newly born; the blood dyscrasiae, such as scurvy, 
purpura, and hemophilia, and infectious diseases, particularly typhoid, 
scarlet fever, influenza, and malaria. In most of these cases the amount 
of blood passed is small. When it is large it may appear in the urine as 
clear blood, or as clots, or it may impart simply a reddish or smoky color 
to the urine. The color, however, is not so reliable as a microscopical 
examination. 

Large hemorrhages are much more likely to conic from the kidneys 
than from the bladder. The presence of blood casts from the renal 
tubules, or larger ones from the ureter, are conclusive evidence of tin- 
renal origin of the hemorrhage. 

The treatment of hematuria should be directed to the cause upon 
which it depends. In infancy scurvy especially should not be overlooked. 



HEMOGLOBINURIA 

Tn this condition blood pigment appears in the urine in large quan- 
tity, but red blood-cells are very few in number or are absent altogether. 
In severe cases the urine niav be almost black. There ifi commonly a 



620 DISEASES OF THE UROGENITAL SYSTEM 

small amount of albumin. This condition may be recognized by the 
appearance of granules of pigment under the microscope, or by Heller's 
test; the most conclusive means of diagnosis, however, is by the spectro- 
scope. 

Epidemic hemoglobinuria (Winckel's disease) has already been de- 
scribed in the chapter on Diseases of the Newly Born. Hemoglobinuria 
may be due to certain poisons, as carbolic acid or chlorate of potash, or 
to certain infectious diseases, as scarlet fever, typhoid fever, malaria, 
syphilis, or erysipelas. 

Paroxysmal hemoglobinuria occurs in childhood, although it is an 
exeedingly rare condition. In most of the recorded cases there has been 
a history of syphilis and the Wassermann reaction has been positive. It 
is now regarded as a syphilitic affection. Paroxysms may be excited by 
exposure to cold, by chilling the surface of the body or by merely im- 
mersing the hands in cold water. Vigorous antiluetic treatment is in- 
dicated. It is not yet clear that it is always entirely successful; it may, 
however, greatly improve the condition. For further description text- 
books on general medicine should be consulted. 



PYURIA 

Pus in the urine may exist as an acute or a chronic condition. In 
either case, in a child, it is much more likely to come from the pelvis of 
the kidney than from any other source. It may, however, come from 
any part of the genito-urinary tract — -the kidney or its pelvis, the ureters, 
the bladder, the urethra, or the vagina. Sometimes it comes from an 
outside source, as when an abscess from perinephritis, appendicitis, or 
caries of the spine opens into the urinary tract. 

Coming from the pelvis of the kidney, pus may indicate, if the con- 
dition is an acute one, pyelitis, pyelonephritis, or pyonephrosis; if it is 
chronic, it may point to renal tuberculosis or calculus. The amount of 
pus in any of these conditions may be quite large. The urine is turbid 
and usually acid in reaction. It contains many epithelial cells of the tran- 
sitional variety. A urine containing much pus is always albuminous. 
It is rare that pus comes from the ureters except in connection with 
congenital malformations or the impaction of calculi. Pus from the 
bladder is not usually in large quantity, and may be mixed with mucus. 
The urine may be alkaline or acid in reaction ; there may be associated 
the symptoms of vesical irritation or of cystitis. Pus from the lower 
genital tract is rare in children, and its causes may often be recognized 
by a local examination. When the cause of pyuria is the opening of 
an abscess into the urinary tract there is generally a sudden appear- 



DIABETES INSIPIDUS 621 

ance of pus in large amount. The pyuria is usually in such eases of 
short duration, possibly only a few days, and it may disappear quite 
rapidly. 

The nature of the infection can be determined only by cultures made 
from a catheterized specimen. This information is of considerable aid 
both in diagnosis and prognosis. 

The treatment of pyuria depends altogether upon its cause. Im- 
provement in the symptoms sometimes follows the use of hexamethyl- 
enamin, which may be given in doses of from five to ten grains three 
times a day to a child of five years. 

ANURIA 

By this term is meant an arrest of the urinary secretion. To that 
form which occurs in the course of renal disease the term "suppres-. 
sion" is generally applied. Anuria is to be carefully distinguished from 
retention, from the scanty secretion which occurs whenever food is re- 
fused or withheld on account of illness, and also from that which accom- 
panies acute diarrhea, with large, watery discharges. Anuria is some- 
times seen in the newly born, where it depends upon some malformation 
of the genital tract; or, more frequently, upon uric-acid infarctions in 
the kidneys. The first urine passed after such an attack is very often 
highly acid, and may contain an abundance of uric-acid crystals and 
larger masses visible to the naked eye. Other cases admit of no such 
explanation. For the time, the secretion appears to be completely ar- 
rested, as the bladder, both by palpation and catheterization, is found to 
be empty. This condition is very uncommon in infancy, and it may con- 
iinue for from twelve to thirty-six hours. So long as infants appear to 
be perfectly normal in every other respect, the suspension of the urinary 
secretion even for twenty-four hours need excite no anxiety. 

The treatment consists in the administration of the acetate or citrate 
of potash, and plenty of water. To a newly-born infant one grain of 
the citrate of potash may be given every hour or two. in water, until the 
urinary secretion is established, which will usually be in six or eight 
hours. If the urine is very highly acid and stains the napkins, the 
potash should be continued for several days. Hot fomentations over the 
kidneys may be used. 

DIABETES INSIPIDUS (POLYURIA) 

This is a chronic disease characterized by the excretion of a very 
large amount of pale urine of low specific gravity. It is invariably 
accompanied by polydipsia. The disease is fare one in children. 



622 DISEASES OF THE UROGENITAL SYSTEM 

Etiology. — Of eighty-five cases collected by Strauss, twenty-one were 
in children under ten years of age and nine under five years. In Kob- 
erts's collection of seventy cases, the disease began in twenty-two chil- 
dren before ten years, and in seven during infancy. In some cases it 
begins soon after birth. Males are more frequently affected than females, 
and in certain cases heredity is an important factor. Weil has published 
a remarkable example of the disease existing in many members of a 
single family. Falls or blows upon the head, concussion of the brain, 
tumors of the brain, and chronic hydrocephalus, all have been found asso- 
ciated with diabetes insipidus. It sometimes has followed the acute 
infectious diseases; but in many cases no cause whatever can be found. 
The association of diabetes insipidus with lesions at the base of the brain 
has long been observed. More recently this symptom has been connected 
with lesions of the pituitary body. Since one of the most frequent lesions 
of the base is chronic syphilitic meningitis, syphilis must be considered 
a possible etiological factor. It is altogether probable that a number of 
quite distinct causes may produce diabetes insipidus. 

Symptoms. — The quantity of urine is enormous, usually exceeding 
even that in diabetes mellitus. From five to twenty pints daily may be 
passed. The urine is pale, the specific gravity from 1.001 to 1.006, and 
it contains neither albumin nor glucose. In a few cases the presence of 
inosite (muscle sugar) has been found. Bestriding the amount of fluid 
taken causes a very marked diminution in the amount of urine. The 
intense thirst leads patients to drink enormously of water and other 
fluids. 

Nervous symptoms are usually present. There may be disturbed 
sleep from the frequent micturition, palpitation, flushing of face and 
other vasomotor disturbances, headache, restlessness, and neuralgia. 
There may be incontinence of urine. The bladder sometimes becomes 
enormously distended. In one of our cases it held forty-five ounces and 
reached above the umbilicus. The skin is pale and dry, and perspiration 
is scanty. The general health may not be much disturbed. In most 
cases, however, it is affected, and there may be the usual symptoms 
of malnutrition, and even neurasthenia. If it affects young children, 
their growth is generally retarded. The appetite usually remains quite 
good but anorexia may be marked. The temperature is at times slightly 
subnormal. The course of the disease is indefinite. It is very chronic, 
and may last for many years, death taking place from intercurrent affec- 
tions. 

Prognosis. — Occasionally a patient will recover spontaneously. Of 
the chronic cases in which the disease is well established very few are 
controlled. The prognosis is especially bad if there are marked disturb- 
ances of the digestive tract or organic brain disease. 



MALFORMATIONS AND MALPOSITIONS 623 

Diagnosis. — This is easily made from the two marked symptoms, 
excessive thirst and polyuria. From diabetes mellitus it is easily distin- 
guished by the lower specific gravity and the absence of sugar from the 
urine. In older children, chronic nephritis with contracted kidney may 
be confounded with it. Its occasional association with syphilis should be 
remembered and a Wassermann test made as a possible basis of treat- 
ment. 

Treatment. — Fluids should be moderately restricted. It is a serious 
mistake to reduce the quantity of fluids too much, since the drinking is 
not the cause of the diuresis. The diet should be simple and nutritious. 
The general treatment should be directed to the condition of malnutri- 
tion. The clothing should be warm, and a moderate amount of exercise 
should be allowed. Drugs, in most cases, are of little use. Bromids and 
belladonna continued for many months are claimed to be of value. Co- 
dein too is said at times to cause decided improvement. It is doubtful 
if the prospect of cure justifies its use for a prolonged time. Treatment 
must be continued for many months to be of any value. 



CHAPTER II 

DISEASES OF THE KIDNEYS 
MALFORMATIONS AND MALPOSITIONS 

Malformations of the kidney are not infrequent. In seven hun- 
dred and twenty-six consecutive autopsies at the New York Infant Asy- 
lum malformations of the kidney or ureters were met with in seventeen 
cases. This does not represent the actual frequency with which they 
occur, for in about half that number of autopsies in two other institu- 
tions only a single example was seen. Adding to the cases mentioned 
two others seen elsewhere, there are twenty cases of renal malformation 
of which we have notes, classed as follows: 

Fusion of the kidneys, or horseshoe kidney 1 cases. 

Supernumerary ureters I 

1 [ydronephrosis (alone) « s 

Congenita] cystic kidney (alone) 2 

Hydronephrosis and cystic kidney I case 

Single kidney 1 

In all malformations the left kidney is much more frequently affected 
than the right, the proportion being nearly two t<> one. Malformations 



624 DISEASES OF THE UROGENITAL SYSTEM 

are more often seen in males than in females. Only two of these con- 
ditions are of clinical importance — viz., cystic degeneration and hydro- 
nephrosis. 

Cystic Kidneys. — Two varieties of this malformation are met with. 
Tn one the cysts are few in number and large ; in the other they are very 
numerous and small. When the cysts are large the renal tumor may fill 
the abdominal cavity, even interfering with the birth of the child. The 
condition is generally bilateral, and the patients die in early infancy. 
The more common form, that with small cysts, also affects both sides 
as a rule. The organ often is not enlarged, and it may even be smaller 
than normal. The surface of the kidney is studded with small cysts, 
which usually vary in size from a pin's head to that of a pea. The entire 
organ may consist of nothing but a mass of cysts, held together by 
loose connective tissue. In other cases the cysts are less numerous, and 
much renal tissue remains. The cysts are formed by the dilatation of 
the uriniferous tubules owing to occlusion, which occurs in the devel- 
opment of the kidney. The large cysts are recognized as abdominal 
tumors; the small ones usually give no symptoms during infancy and 
childhood and are found accidentally at autopsy in patients dying from 
other diseases. In either form uremic symptoms may develop if an 
insufficient quantity of functionating renal substance remains. 

Hydronephrosis. — This renal lesion in a mild form is not very un- 
common at autopsy when no physical signs or symptoms have been given 
during life. In more severe form it is associated with many of the mal- 
formations of the organ such as horseshoe kidney, cystic kidney, etc. It 
may affect one or both sides and be found in both males and females. 
Hydronephrosis is undoubtedly the result of some obstruction to the out- 
flow of urine from the kidney, ureter or bladder, but this obstruction 
may be very difficult to demonstrate. Obvious causes for hydronephrosis 
are stones in the kidney, ureter or bladder and pressure upon the urinary 
tract by tumors. 

The ureter is generally dilated to a diameter of from one fourth to 
one half inch and it may be so large as to be easily mistaken for the 
intestine. Usually the ureters appear much elongated and sacculated ; 
the pelvis and the calices of the kidney may be slightly dilated or the 
greater part of the kidney may be destroyed, leaving only a series of 
communicating pockets surrounded by a thin cortex of renal tissue. 
After a time chronic nephritis usually develops. This may involve both 
kidneys, even though the hydronephrosis is unilateral. 

If hydronephrosis is unilateral there may be no symptoms until the 
dilatation of the pelvis of the kidney has reached a sufficient size to 
form an abdominal tumor. In most of the cases in children this condi- 
tion has been noted between the third and the eleventh years. This 



MALFORMATIONS AND MALPOSITIONS 625 

tumor may be situated in the lumbar region, or it may fill the abdomen. 
It is cystic, and may be confounded with a dermoid cyst of the ovary. 
On aspiration a fluid is withdrawn which may be clear, or of a brownish 
color, and recognized as urine by the fact that it contains urates and 
urea. After aspiration the urine passed per urethram may be bloody. 
Aspiration affords only temporary relief, as the tumor quickly refills. 
The treatment is surgical. When the other kidney is normal nephrectomy 
often results in a permanent cure. 

Double hydronephrosis occurs much more frequently in the male. 
In infants and young children it not infrequently causes a definite and 
characteristic group of symptoms. It may be found in infants a few 
weeks old or throughout childhood. Double hydronephrosis, however, 
is generally associated with, or results in, such changes in the kidneys 
that the patients die during infancy. 

The cause of double hydronephrosis is usually to be found in the 
posterior urethra. While several abnormalities have been described the 
most common one is an exaggeration of the normal folds of mucous 
membrane that lead from the verumontanum to the wall of the urethra. 
These folds are sometimes greatly hypertrophied and so situated as t<> 
make a diaphragm across the urethra in which there is usually a small, 
slit-like opening. There is thus produced a great obstacle to the passage 
of urine. The changes produced in the bladder, ureters and kidney arc 
very extensive. The bladder is much increased in thickness but is not 
dilated. The walls of the bladder may be as much as a quarter or a 
third of an inch in thickness. The ureters are greatly dilated and are 
often an inch or more in diameter. They are tortuous, their walls are 
thickened and thrown into folds. The kidneys are increased in size, due 
entirely to the hydronephrosis, for, as a result of this, the renal substance 
may be reduced to a minimum. They consist of a mass of dilated, com- 
municating cystic spaces surrounded by a shell of renal tissue. The 
structure of cortex and medulla may be indistinguishable. Secondary 
infection not infrequently occurs, in which case the bladder, ureters and 
kidneys may contain pus and there may be abscesses in the substance of 
the kidney. An excellent example of this condition is shown in Fig. 84. 
The damage to the kidneys may he so great thai the infant dies shortly 
after birth. When it is less, life may he prolonged for months or years. 

The history is at times quite characteristic. There may have horn 
difficulty in urination and dribbling of urine from birth or it may not 
have been noticed until the child was a year or two old. or perhaps <'\<'ii 
later. With each attempt to pass urine only a small quantity is expelled 
after much straining. Examination of the abdomen shows a linn. 
globular mass in the hypogastrimn which remains even after urination. 
Leading up from this into the loin on each side there ma\ often be fell 



626 DISEASES OF THE UROGENITAL SYSTEM 

masses sometimes elongated, sometimes globular, which are the twisted 
tortuous ureters. The kidneys may or may not be felt. In the bilateral 
form of hydronephrosis the renal tumors are usually not large, as life 
would be impossible with the destruction of much renal substance on 
both sides. The masses may vary in size but the tumor formed by the 
bladder is the most constant one. 




Fig. 8±. — Congenital Hydronephrosis, Dilated Ureters, and Hypertrophied 
Bladder. (From a child one month old.) 

Changes in the urine may not be present until the condition is far 
advanced. There may be all the symptoms of chronic diffuse nephritis or 
when infection of the genital tract occurs, there are added the symptoms 
of pyonephrosis. The course is usually progressive. More and more 
damage to the kidneys takes place until death results from uremia, from 
secondary infection, or from some intercurrent disease. 

The treatment is surgical. The obstruction should be removed. If 



URIC-ACID INFARCTIONS 627 

this is done early before extensive changes in the kidneys have taken place 
life may be indefinitely prolonged. We have had two patients, three and 
four years of age, operated upon with very satisfactory results. 

Movable Kidney. — This is a rare condition in young children. 
Comby has collected eighteen cases, of which sixteen were in girls and two 
in boys. Movable kidney was recognized before the tenth year in eight 
cases, and in two of these before the fourth month. It has been ascribed 
to too long a pedicle, which may be congenital; also to pressure from 
abdominal tumors and to injury. The most important symptoms are 
paroxysmal pain which may follow exertion, and a movable tumor. A 
twist in the ureter may produce hydronephrosis. 



URIC-ACID INFARCTIONS 

These consist in a deposit in the straight tubes of the kidneys of uric 
acid or of amorphous or crystalline urates; usually both kidneys are 
affected, and all the pyramids of each kidney. The infarctions appear 
to the naked eye as fine, brownish-yellow, fan-shaped striae. Associated 
with them there may be granular deposits of uric-acid salts in the pelvis 
of the kidney, and sometimes evidences of catarrhal inflammation of the 
pelvis, including even the presence of blood. This condition probably 
occurs, to some degree at least, in nearly all infants during the first ten 
days of life. It was formerly supposed that the discovery of these ap- 
pearances was proof that an infant had breathed, and a certain medico- 
legal importance was therefore attached to them. This is now known 
not to be the case, as they are sometimes found in still-born infants. 

The cause of this condition is the excretion of uric acid before there 
is sufficient water to dissolve it, so that the crystals are deposited in the 
tubes. Uric-acid infarctions are found chiefly in children dying before 
the end of the second week, although it is not uncommon to see them as 
late as the third or fourth or even the sixth month. In most of the 
cases, as the urinary secretion becomes more abundant, the deposits are 
washed out in the urine and appear as brownish-red or pink stains upon 
the napkins. Infarctions may give rise to a slight inflammation of the 
renal tubules, but very rarely to any serious lesion: sometimes they 
remain as deposits in the calices or the pelvis of the kidney or in the 
bladder, forming the nuclei of calculi. The symptoms to which they 
give rise are mainly scanty urination during the first week of life, and 
occasionally anuria for the first day or two. Sometimes there i< evidence 
of severe pain; priapism may be present, and there is the stain upon the 
napkin already referred to. The treatment is to give water freelj and 
some alkaline diuretic such as citrate of potash. One grain should he 



628 DISEASES OF THE UROGENITAL SYSTEM 

given every two hours until the secretion is fully established ; this in most 
cases will be within twenty-four hours. 



CHRONIC CONGESTION OF THE KIDNEYS 

This results from interference with the return circulation of the 
kidney, and may be caused by congenital malformation or valvular dis- 
ease of the heart, chronic bronchopneumonia or chronic pleurisy; also 
by the pressure of any abdominal tumor upon the inferior vena cava 
or the renal veins. 

The kidneys are generally enlarged, firmer than normal, and dark- 
colored. All the capillary vessels are swollen and distended with blood, 
and their walls are thickened. In addition to the symptoms of the pri- 
mary disease, the amount of urine passed is usually scanty and of high 
specific gravity. Albumin and casts are generally present, but are not 
constant. The treatment should be directed toward the primary condi- 
tion, and, in addition, an effort should be made to increase the amount of 
urine by alkaline diuretics, caffein, digitalis, and the sodium salicylate of 
theobromin. 

ACUTE DEGENERATION OF THE KIDNEYS 

In the succeeding pages devoted to the kidney Prudden's classifica- 
tion in the main has been followed. 

In acute degeneration of the kidney the principal or only change is 
in the epithelium of the tubules. It is exceedingly common both in in- 
fancy and in childhood, being found to a greater or less degree in all 
autopsies upon patients dying of acute infectious diseases, but it is most 
marked in cases of scarlet fever, diphtheria, and acute pleuropneumonia. 
It may be found in any disease characterized by prolonged high tempera- 
ture, and it is the explanation of the cases of so-called febrile albu- 
minuria. The cause is in all probability direct irritation of the epi- 
thelium of the tubules by the toxins eliminated by the kidneys. It may 
also be induced by irritating drugs, such as cantharides or turpentine. By 
some writers these cases have been classed as examples of acute nephritis ; 
hence the great discrepancy which exists in statements made as to the 
frequency of nephritis in the different infectious diseases. 

The kidneys are usually slightly enlarged, softer, and paler than 
normal. On section the cortex may be somewhat thickened, and the 
straight tubules marked by yellowish-gray lines. It is the appearance 
commonly spoken of as cloudy swelling. The kidneys are seldom much 
congested. The microscope shows a granular degeneration of the epathe- 



ACUTE DIFFUSE NEPHRITIS 629 

lium of the tubules, and when severe this may be accompanied by conges- 
tion and the exudation of serum. 

Acute degeneration of the kidneys gives rise to no symptoms in addi- 
tion to those of the original disease, except the appearance of a moderate 
amount of albumin in the urine, with a few hyaline, granular, or epi- 
thelial casts. It can not be said that such a condition adds much to the 
danger from the original disease. In cases that recover, the condition of 
the kidney becomes entirely normal. The development of the symptoms 
of degeneration of the kidneys in infectious diseases calls for no special 
treatment beyond a continuance of the fluid diet. 



ACUTE DIFFUSE NEPHRITIS 

(Acute Interstitial Nephritis; Acute Exudative Nephritis; Glomerulonephritis; 

Acute Bright's Disease.) 

Etiology. — This variety of nephritis occurs apparently as a primary 
disease both in infants and in older children. Most such cases are un- 
doubtedly of infectious origin, although the point of entrance of the 
infection it may be difficult or impossible to determine. Acute diffuse 
nephritis is very frequently secondary to the acute infectious diseases. 
especially to scarlet fever and diphtheria. It occasionally follows measles, 
varicella, empyema, typhoid fever, acute diarrheal diseases, pneumonia, 
meningitis, influenza, and malaria. It is the characteristic variety of 
secondary nephritis occurring in severe septic conditions. Some children 
exhibit a predisposition to this disease and develop acute nephritis with 
almost any infectious disease, however mild, which they contract. The 
exciting cause of the inflammation is in some eases the irritation from 
toxins; but usually there is in addition the entrance of pathogenic organ- 
isms carried by the circulation. Thus in post-scarlatinal nephritis, of 
which the one under consideration is the characteristic form, the cause is 
now generally admitted to be the toxins of the primary disease, to which 
in many cases is added infection by the streptococcus. While uephritis 
is more frequent after severe attacks of scarlet fever, it may occur after 
those which are very mild, even when patients have been kept in bed 
throughout the disease. The frequency of nephritis as ;i sequel of scarlet 
fever varies much in different epidemics; the average is from Bis t<« fceu 
per cent. We have seen two cases of acute uephritis in infants, the 
apparent cause of which was the irritation of a highly concentrated mine. 
This was the result of the infants taking for a long time very little 
food and almost no water. 

Lesions. — In severe cases the kidneys are usually enlarged, Boft, and 
edematous. The capsule is non-adherent. The cortex is thickened, either 



636 DISEASES OF THE UROGENITAL SYSTEM 

reddened or pale ; frequently it is mottled with red, owing to the presence 
of small hemorrhages. There may be congestion of the entire organ; 
or the pyramids may seem unusually red by contrast with the pale and 
thickened cortex. 

All the structures of the kidney — glomeruli, tubular epithelium, and 
interstitial tissue — are involved in the inflammatory process. The cells 
covering the glomerular tufts of capillaries are swollen and proliferated. 
They have frequently undergone fatty degeneration. The epithelial cells 
lining Bowman's capsule may undergo the same changes, but usually to 
a lesser degree. The space between the capsule and the tuft may contain 
exfoliated epithelium in considerable quantity, also cell-detritus, albu- 
minous (granular) exudate, leucocytes, and red blood-cells. The tubular 
epithelium undergoes albuminous and fatty degeneration and may des- 
quamate. Thus the tubules may contain epithelial fragments, serum, 
red blood-cells, leucocytes, and casts. The interstitial connective tissue is 
infiltrated with serum and in places with small round cells. In cases of 
longer duration a general increase of the connective tissue may take 
place, which is permanent. 

When the glomerular changes are especially marked, as in acute 
nephritis following scarlet fever, the process is often spoken of as 
glomerulonephritis. If the degeneration of the tubular epithelium is 
extreme, as in severe cases of diphtheria dying shortly after the onset, 
the nephritis may be described as the parenchymatous or degenerative 
type. In the hemorrhagic form there are hemorrhages into the tubules, 
glomeruli, or interstitial tissue. In infants and young children the exu- 
dative type of acute diffuse nephritis is especially frequent. In this 
there is an exudative inflammation with large accumulations of leucocytes, 
serum, and red blood-cells in the glomeruli and tubules, the parenchyma 
and interstitial tissue sometimes being markedly and sometimes but 
slightly changed. Should the interstitial tissue suffer early and severely, 
the nephritis becomes of the productive or interstitial type. This form is 
most frequently seen with severe, protracted cases of scarlet fever and 
diphtheria, especially in older children. It sometimes occurs as an ap- 
parently independent process. 

Symptoms. — 1. Primary Form in Infants. — These cases are not com- 
mon, and the symptoms are so obscure that they are often overlooked. 
A number of such cases have come under our observation. The inflamma- 
tion in most of them was of the exudative type. 

The onset in nearly every instance was abrupt, usually with high 
fever and vomiting, the temperature being in several cases over 104° F. 
Dropsy was exceptional; in most of these it was slight, and seen only 
toward the close of the disease. Fever was present in all cases. In those 
observed by us it was high and irregular in type, ranging from 101° to 



ACUTE DIFFUSE NEPHRITIS 631 

105° F. The duration of the disease was from one to four weeks, the 
average being about two and a half weeks. Vomiting and diarrhea were 
noted in half the cases, but were rarely prominent, and marked either 
the onset of the attack, or were traceable to indigestion accompanying 
the fever; very rarely did they exist as symptoms of uremia. Anemia 
was a prominent symptom in nearly every case, and it was this which 
called attention in several instances to the renal condition. Nervous 
symptoms were usually prominent. In several patients there was 
dyspnea without pulmonary disease and without cyanosis, partly due 
perhaps to the marked anemia, but probably due chiefly to the develop- 
ment of acidosis. In nearly all cases there was marked restlessness or 
muscular twitchings, and in three there were convulsions. Dullness 
and apathy were present in the majority of the fatal cases, but deep 
coma was never seen. The urine was rarely scanty until near the close 
of the disease, and sometimes not even then. Suppression of urine 
was seldom seen. Albumin was frequently absent early in the attack, 
but was invariably present at a late period, although rarely in large 
amount. Casts were found in all cases that were carefully examined 
microscopically. They were not usually numerous, and were chiefly of 
the hyaline, granular, and epithelial varieties. Xo blood casts were 
seen. There were usually many pus cells and renal epithelial cells, 
together with red blood-cells in moderate numbers. 

Of the thirty-four cases collected, including our own, twenty-five 
died and only nine recovered. Whether these figures represent the actual 
mortality of the disease it is difficult to' say. No douhl there are many 
mild eases which are unrecognized. The severe ones, however, are quite 
uniformly fatal, chiefly on account of the tender age of the patients. 

'1. Primary Form in Older Children. — This also is a pare form of 
renal disease. The onset is usually less abrupt than in infants, the 
febrile symptoms are less marked, and the termination is less frequently 
fatal. Dropsy is rarely marked, and often is absent. The urine is only 
slightly diminished in quantity; the amount of albumin is Bmall; casts 
are not numerous, and usually hyaline, epithelial, or granular; very rarely 
is there much blood present. Uremia is infrequent, and the prognosis is 
better than in infancy. The course may he very prolonged; hut even 
when albuminuria has lasted several months recovery may be complete. 

The interstitial type may begin abruptly with febrile symptoms. 
dropsy, headache, lumbar pains, scanty urine, and often with vomiting; 
or it may come on somewhat insidiously with few constitutional symp- 
toms, but with dropsy and changes in the urine. 

3. Secondary Form. — The secondary nephritis of acute infections dis- 
eases may occur at the height of the febrile process or .-it n later period, 
and its severity is generally proportionate to the intensity of the infection. 



632 DISEASES OF THE UROGENITAL SYSTEM 

The general symptoms of nephritis are often not marked, and dropsy 
is rare ; so that unless the nrine is examined the condition may be over- 
looked. The urinary changes are essentially the same as those already 
mentioned in the primary cases. Suppression of urine and the develop- 
ment of the symptoms of acute uremia are infrequent. While nephritis 
adds considerably to the danger from the primary disease, it is seldom 
itself the cause of death, although this is sometimes the case in scarlet 
fever and diphtheria. 

The characteristic type of nephritis which follows scarlet fever most 
frequently develops during the third or fourth week of the disease. The 
onset may be gradual, dropsy being first noticed. Or it may begin 
abruptly without dropsy, but with headache, vomiting, scanty urine, fever, 
and even convulsions. The temperature generally ranges from 100° to 
101.5° F., but in very severe attacks it may be 104° or 105° F. While 
dropsy is usually present, it may be slight or absent in severe and even in 
fatal cases. It is first seen in the face, next in the feet, legs, and scrotum ; 
there may be general anasarca, with dropsy of the serous cavities of the 
body, the pleura, or the peritoneum, rarely the pericardium. As the 
disease progresses there is always a very marked degree of anemia. 

The urine is, as a rule, greatly diminished in quantity, and may be 
suppressed. Albumin is invariably present, although not always at first; 
it is usually in large amount, often enough to render the urine solid 
upon boiling. The urine is of a dark, reddish-brown or smoky color, 
owing to the presence of red blood-cells or hemoglobin. The specific 
gravity may be low, even though the quantity is very small. Casts are 
present in great numbers, chiefly hyaline, granular, and epithelial casts 
from the straight tubes; not infrequently there are blood casts. Red 
blood-cells are present in great numbers ; also many leucocytes, and renal 
epithelium. 

The duration of the active symptoms in cases terminating in recovery 
is from one to three weeks. The temperature and dropsy gradually sub- 
side. Improvement in the urine is shown by an increase in quantity, by 
an increased elimination of urea, and by a diminution in the amount of 
blood, albumin, and the number of casts. A few casts may persist for 
several weeks, and a small amount of albumin for two or three months. 
In the graver cases, when the onset is accompanied by high temper- 
ature, pain in the back and loins, and a rapid, full pulse of high tension, 
the urine is very scanty and is often suppressed. Then follow the symp- 
toms of uremia. In children this is usually manifested by vomiting, 
great restlessness or apathy, and often by diarrhea. Hyperpnea is not 
infrequent and is usually evidence of acidosis. Less frequently there is 
headache, dimness of vision, stupor developing into coma, or convul- 
sions. If the secretion of urine is re-established, the nervous symptoms 



ACUTE DIFFUSE NEPHRITIS 633 

abate and the patient may recover. This has been known to occur 
after complete suppression has lasted thirty-six hours. Care should be 
taken not to mistake retention for suppression. If doubt exists, percus- 
sion of the bladder and the use of the catheter will quickly settle the 
question. 

There are several complications for which the physician must con- 
stantly be on the lookout during attacks of acute nephritis; the mosi 
frequent are pneumonia, pleurisy, pericarditis, and endocarditis ; more 
rarely there may be meningitis and edema of the glottis. It is from 
complications or acute uremia that death usually occurs. 

Prognosis. — This is to be considered from two points of view: first, 
the danger to life during the acute stage of the disease, and. secondly. 
the danger of the development of chronic nephritis. The majority of 
patients survive the acute stage, and not infrequently even those re- 
cover who have presented grave symptoms of uremic poisoning. The 
quantity and specific gravity of the urine, the delayed elimination of 
phenolsulphonephthalein, and the number and variety of the easts, arc 
a much better guide in prognosis than the amount of albumin. The 
existence. of acidosis and of severe nervous symptoms, such as stupor, 
intense headache, dimness of vision, and persistent vomiting, add much 
to the gravity of the case, as does also the presence of any serious com- 
plication. In general it may be said that if there is no suppression of 
urine, or if there are no symptoms of uremia and no complications, 
recovery is almost certain if the child is over three years old ; in younger 
children the outlook is less favorable. The general opinion prevails thai 
acute diffuse nephritis in childhood, whether it is primary or occurs as 
a complication of scarlet fever, is rarely followed by the chronic form 
of the disease; and such was the view we formerly held. Larger experi- 
ence, however, has convinced us that this sequel is not very uncommon. 
The interval of apparent health may sometimes cover a period of several 
years, and the later nephritis may be attributed to other causes; hut all 
cases of scarlatinal nephritis should he carefully watched lor a long time, 
and after a severe attack a guarded prognosis should always he given as 
regards the ultimate result. 1 

Treatment. — Prophylaxis is important, and relates principally to the 

x The following case may be cited as an illustration of this point: A girl 
at the age of seven years had scarlet lexer, followed by nephritis; the dr< 
having lasted, it was reported, for three months. She was believed to have 
recovered perfectly, and remained in apparent health until she was sixteen, when, 
as a supposed result of a severe chilling, she developed dropsy and all the symp- 
toms of acute nephritis. From that time, although she lived for three years, 
and was often for months at a time seemingly in the best of health, her urine 
was never free from casts and albumin, and shr finally died in uremic convul- 
sions. 



634 DISEASES OF THE UROGENITAL SYSTEM 

secondary form which occurs in the course of infectious diseases, espe- 
cially to post-scarlatinal nephritis ; but the measures here outlined apply 
equally to all varieties. The inflammation of the kidney being in most 
of these cases the result of direct irritation by the toxins which are elim- 
inated by them, it follows that elimination through the skin and intes- 
tines should be increased, and that the urine should be rendered as little 
irritating as possible by largely increasing its quantity. The first indi- 
cation is met by frequent sponging, warm baths, and keeping the bowels 
freely opened by saline cathartics, sufficient being given to produce one 
or two loose movements daily. To meet the second indication, the pa- 
tient should be kept upon a diet of milk and farinaceous food, at least 
for the first three weeks of the disease, and, if possible, for a full month. 
At the same time he should drink very freely of alkaline mineral waters, 
or of plain water. If milk is not well borne, kumyss, whey, or butter- 
milk may be used, or thin gruels mixed with milk. When the first 
trace of albumin appears in the urine this plan of treatment should in- 
variably be followed. In addition to these measures, after an attack of 
scarlet fever the patient should be kept in bed for at least a week after 
the temperature has become normal. 

The mild cases of acute nephritis tend to spontaneous recovery under 
the hygienic and dietetic treatment outlined, i. e., rest in bed, the diet 
mentioned, the drinking of large quantities of water, and attention to the 
action of the skin and bowels. These measures should be continued so 
long as the urine contains any considerable amount of albumin, or so 
long as the patient's general condition will permit. Should he become 
very anemic, or lose much in weight, it may be necessary to enlarge the 
diet by the addition of more solid food. An increase in the diet and 
exercise should be made very gradually, and the effect upon the urine 
carefully watched. 

The severe cases, with scanty urine, fever and marked dropsy, re- 
quire more active treatment. Free diaphoresis should be maintained by 
the hot pack or vapor bath. Active counter-irritation should be used 
over the kidneys by dry cups followed by poultices, or the mustard 
paste. Two or three loose movements from the bowels should be secured 
by the administration of calomel or, better by Eochelle or Epsom salts. 
Harm is sometimes done by carrying this depletion too far, and its 
effect upon the patient's general condition must be closely watched. If 
suppression of urine occurs with the development of uremic symptoms — 
delirium, vomiting, diarrhea, and a pulse of high tension — venesection 
should be practiced ; from three to six ounces of blood may be drawn from 
a child of five years, according to his general condition and the urgency 
of the symptoms. The depressing effect may largely be overcome by im- 
mediately following this with an intravenous injection of a normal salt 



CHRONIC NEPHRITIS 635 

solution. Twice as much as the fluid drawn should be introduced. This 
will almost invariably give at least temporary relief, which may afford 
time for the operation of other measures, such as catharsis and diaphore- 
sis. Pulmonary edema is rather an indication to bleeding; the best of 
all guides as to its use is a pulse of very high tension. 

In addition to these measures rectal injections of a normal salt solu- 
tion may be given high in the colon, at a temperature of from 104° 
to 108° F. At least two quarts should be given several times a day, to be 
continued until a free flow of urine is established. This is one of the 
most valuable means we possess of increasing elimination by the kidneys 
and skin. 

The nervous symptoms of uremia are best relieved by chloral, which 
should be given per rectum. When such symptoms are marked, from 
six to ten grains are required for a child of five years, to be repeated 
in two hours if no improvement is seen. Uremic convulsions may some- 
times be averted by the use of morphin hypodermically. 

One should always be on the lookout for complications, especially 
dropsy of the serous cavities, pericarditis, and edema of the lungs. Con- 
valescence is nearly always slow, and a patient who has suffered from 
nephritis needs careful attention for a long time. Anemia is always 
present, and iron is required. The diet should be carefully restricted 
for several months; much nitrogenous food should be avoided. If the 
disease tends to pass into a subacute form, the child should, if possible, 
be sent to a warm climate, and kept there during the succeeding winter, 
and every means taken to improve the general nutrition. Flannels 
should be worn next to the skin, and special precautions taken against 
any exposure which might cause an exacerbation of the disease. 



CHRONIC NEPHRITIS 

Chronic inflammation of the kidney is an infrequent condition in 
childhood. In infancy it is almost unknown, except in connection with 
congenital hydronephrosis or other malformations of the kidney. Two 
pathological varieties are met with: (1) chronic diffuse uephritis of 
the parenchymatous or degenerative type; (2) chronic diffuse nephri- 
tis of the interstitial or productive type. As the disease progr< the 

former may assume the characteristics of the latter variety. 

Etiology. — Chronic nephritis is mosl frequently Been as a sequel of 
the acute nephritis of scarlet fever, less often after other acute infections. 
The only other important causes in early life are hereditary syphilis, 
chronic tuberculosis, and valvular disease of the heart. Nearly all the 
cases occiii- in children over five years of age. 



G36 DISEASES OF THE UROGENITAL SYSTEM 

Lesions. — The lesions of chronic nephritis in childhood do not differ 
essentially from those seen in later life. In the chronic parenchymatous 
type the kidneys are usually enlarged, the surface is smooth or slightly 
nodular, and the thickened cortex yellowish-white on section. These are 
often called "large white kidneys." On the other hand, the kidneys 
may be nearly normal in appearance, or smaller and with a thinner cortex 
than is usual. In the so-called "large red kidneys" the cortex is red or 
mottled red and yellow, owing to hemorrhages into the tubules or in- 
terstitial tissue. The microscope shows that the renal epithelium is 
swollen, granular, fatty, and degenerated. The tubes contain leucocytes, 
red cells, cast matter, and the detritus of broken-down epithelial cells. 
In some places they are dilated, in others atrophied. In the glomeruli 
there is a growth of cells, compression and atrophy of the tufts, with the 
formation of new connective tissue. 

In the chronic diffuse nephritis of the interstitial type (granular 
kidney) the organs are smaller than normal, with a nodular surface and 
adherent capsule. The cortex is thinned, and the color is gray or red. 
In addition to the lesions found in the preceding variety, there is an 
extensive production of new connective tissue, which is irregularly dis- 
tributed throughout the kidneys. The tubules in some places are dilated 
to form cysts of considerable size, while in others they have completely 
disappeared. The glomeruli may be atrophied to little fibrous balls; 
or if chronic congestion has preceded the inflammation, some may be 
large and the capillaries dilated with hyaline degeneration of their 
walls. 

Symptoms. — 1. Chronic Nephritis of the Parenchymatous Type. — ■ 
This form of the disease may be chronic from the outset, or follow an 
acute attack from which the patient is often believed to have recovered 
completely. The symptoms sometimes immediately follow the acute 
attack ; at others there is an interval of apparent recovery, extending 
over a few months or even years. Very rarely no such history of an 
antecedent acute attack can be obtained and the symptoms come on 
gradually and insidiously. Such cases occur chiefly in older children, 
and their clinical features do not differ essentially from those of adult 
life. 

As a rule dropsy is present, although it is variable in amount, and 
fluctuates considerably from time to time. There may be not only 
edema of the cellular tissue, but effusion into the pleura, the peritoneum. 
and even the pericardium. As the case progresses, anemia is always a 
marked symptom. There are various disturbances of digestion — loss of 
appetite, occasional vomiting, and attacks of diarrhea. From time to 
time nervous symptoms may be quite prominent, such as headaches, sleep- 
lessness, neuralgia, fatigue upon slight exertion, and dyspnea. Acidosis 



CHRONIC NEPHRITIS G37 

may develop as it flue.- in the nephritis of adults. Attacks of epistaxis 
are not infrequent. 

For the greater part of the time the urine contains albumin and 
easts. They vary much in amount at different periods in the disease, 
according to the rapidity of its progress. During periods of exacerbation, 
both albumin and casts are very abundant, while in the intervals the 
amount of albumin may be small and the casts few. The casts are 
hyaline, granular, epithelial, and fatty. The daily quantity of urine is 
much reduced during the periods of exacerbation, while at other times 
it may be nearly normal. The specific gravity is usually normal or high. 

If amyloid degeneration is present, there are generally associated with 
the renal symptoms, others dependent upon amyloid changes in other 
organs. The spleen and liver are enlarged; there may be ascites and 
diarrhea, and there is usually present a peculiar alabaster cachexia. 

The duration of this form of chronic nephritis depends much upon 
the surroundings of the patient and the treatment. It is rarely shorter 
than two years, and it may last for many years. The progress is always 
irregular and marked by periods of exacerbation and remission. The 
patients die from acute uremia, from some intercurrent disease, or from 
complicating pneumonia, pleurisy, pericarditis, endocarditis, or from 
pulmonary edema. 

2. Chronic Nephritis of the Interstitial Type. — This is a very rare 
disease in early life, being much less frequent even than the preceding 
variety of nephritis. In some cases there is a history of hereditary 
syphilis; in others, of chronic alcoholism. The early symptoms are few, 
and the disease usually develops insidiously. The urine is pale, exces- 
sive in amount, and of low specific gravity — 1.001 to 1.008. Albumin 
is often absent, and, when found, the quantity is small. Dropsy like- 
wise is rare, and never marked. Nervous symptoms are often prominent, 
such as headache, attacks of spasmodic dyspnea resembling asthma, 
neuralgias, and disturbances of vision. High blood-pressure and hyper- 
trophy of the left ventricle are regular symptoms; and even atheroma- 
tous degeneration of the arteries may be present. Dickinson reports an 
instance of this in a patient only six years of age. Late in the disease, 
hemorrhages may occur, and these may be the cause of death. Filatow 
has reported a cerebral hemorrhage in a child of eleven years. Acute 
uremia with acidosis is. however, the usual termination of this form of 
nephritis. The course is slow, and the disease may be overlooked until 
the filial uremic symptoms occur. 

Prognosis. — The prognosis of chronic nephritis a- to complete recov- 
ery is always unfavorable; and although cases are seen in which symp- 
toms are absent for several years, they almost invariably return. \~ 
to the duration of the disease, ii" exacl prognosis can be given, be< 



638 DISEASES OF THE UROGENITAL SYSTEM 

from the symptoms it is difficult or impossible to determine exactly the 
extent of the disease in the kidney and the rapidity of its progress. The 
continued passage of a large amount of urine of low specific gravity is in- 
variably to be interpreted as evidence of fibroid changes in the Mal- 
pighian tufts, and is a bad symptom. A large amount of dropsy, the 
coexistence of valvular disease of the heart, and marked renal insuf- 
ficiency, as shown by the quantitative examination of the urine and 
by the phenolsulphonephthalein test, are all very unfavorable symp- 
toms. 

Diagnosis. — Chronic nephritis, like the acute forms, is likely to be 
overlooked because of the failure to examine the urine in children. 
Eegular and frequent examinations should be made in all cases of con- 
vulsions, of persistent or frequent headaches, severe anemia, hypertrophy 
of the heart, high blood-pressure and of general malnutrition, as well 
as when the more obvious symptoms of renal disease, such as dropsy and 
scanty urine, are present. Nor should one be too ready to make the 
diagnosis of functional albuminuria because he finds albumin only oc- 
casionally and in small quantity. All such cases demand most careful 
observation and the closest attention for a long period before excluding 
organic renal disease. 

Treatment. — Children with chronic nephritis are to be treated on the 
same general plan as adults. The purpose of treatment is to retard as 
much as possible the progress of the disease and to relieve the symptoms 
as they arise. It is of the greatest importance to remove the patient 
from conditions in which exacerbations are liable to occur. If it is pos- 
sible, he should be sent to a warm, dry climate in winter, and all exposure 
to cold avoided ; an out-door life is desirable. Most patients require gen- 
eral tonic treatment with very moderate but regular exercise, never car- 
ried to the point of fatigue, as much rest as possible in a recumbent 
position, a fluid diet, consisting largely of milk as long as this can be 
borne, and the administration of iron. Dropsy calls for a salt-free diet, 
diuretics, saline cathartics, and vascular stimulants. If uremia de- 
velops, with high arterial tension and stupor, headache, and convul- 
sions, venesection should be resorted to, or nitroglycerin used. Mor- 
phin may be given hypodermically if the nervous symptoms are very 
marked. 

Decapsulation of the kidney is to be considered in cases growing 
progressively worse in spite of medical treatment. The immediate risks 
of the operation are rather less than would be expected. We have seen 
striking temporary benefit in several cases when this operation was 
done upon young children. In no case, however, was the improve- 
ment permanent, all the patients dying within a year after it was per- 
formed. 



TUMORS OF THE KIDNEY 639 



TUBERCULOSIS OF THE KIDNEY 

In general tuberculosis, miliary tubercles are frequently seen both 
upon the surface of the kidney and in its substance. These give rise to 
no symptoms and are of no clinical importance. Larger tuberculous 
deposits are extremely rare in early life. They usually occur in patients 
who are the subjects of general tuberculosis, and are associated with 
tuberculosis of other parts of the genito-urinary tract, or they may exist 
as apparently the primary and only tuberculous lesion in the body. As- 
cending infection occurs occasionally but it is rare; nearly all cases arc of 
the descending type, i. e., primary in the kidney. Infection of the kidney 
therefore generally takes place through the circulation and not from the 
bladder. Aldibert's figures show that in children the bladder usually 
escapes even when the kidneys are tuberculous, for of thirteen cases of 
renal tuberculosis the bladder was involved in but two. The disease when 
primary begins in the cortex, but soon extends to the mucous membrane 
of the pelvis and the calices of the kidney, and also to the pyramids. 
As a rule, but one kidney is affected. The process may be confined to 
the pyramids, where are found cheesy nodules which may be single or 
multiple. These ultimately break down and form abscesses. The process 
may result in almost complete destruction of the pyramids, and even of 
portions of the cortex, so that the kidney may consist of a mere shell of 
renal tissue. Suppuration in the neighborhood of the kidney (peri- 
nephritic abscess) often coexists. 

The symptoms are quite indefinite. There may be localized pain and 
tenderness in the region of the kidney, and a tumor if there is peri- 
nephritis. The symptoms of irritability of the bladder may he almost ;i- 
severe as in cases of calculus. Pus usually appears in the urine as a con- 
stant symptom, and blood is often present. But the only tiling that is 
diagnostic is the discovery of tubercle bacilli in the urine. 

The treatment is the same as in adults. 



TUMORS OF THE KIDNEY 

In the great majority of cases tumors of the kidneys are malignant. 
Of fifty-one cases collected by Aldiberl which were operated upon, forty- 
eight were malignant, and three benign. 

Malignant growths are almost invariably primary. In children under 
five years, although not common, they are yet more frequent than any 
other variety of malignant tumor of the abdomen. Nearly all these 
tumors belong to the class of embryonal adenos;ir< oin.i. They contain 



640 DISEASES OF THE UROGENITAL SYSTEM 

remnants of fetal tissue and in many instances are undoubtedly congeni- 
tal. Tumors growing from the adrenals belong to a different group — 
hypernephroma. Eenal tumors may grow from the cortex of the kidney, 
or from the pelvis, sometimes from the adrenals. They may infiltrate 
the whole kidney, so that there is no trace of renal structure remaining, 
or they may form an immense tumor on one side of the kidney, which is 
only partially invaded. These tumors are very rarely cystic, but the}' 
are quite soft, and hemorrhages often occur into their substance. There 
may be secondary growths in the liver, the lungs, the retroperitoneal 
glands, in the opposite kidney, the intestines, the pancreas, and rarely in 
the skull. Pressure of the tumor upon the ureter may lead to hydro- 
nephrosis, and upon the inferior vena cava, to thrombosis of that vessel. 
As it grows, the tumor sometimes becomes adherent to nearly all the 
abdominal organs by localized peritonitis. It may lead to ascites, but it 
very rarely causes general peritonitis. The growth may reach a great 
size, usually from five to fifteen pounds, but in one case reported by 
Jacobi it weighed thirty-six pounds. In Seibert's collection of forty- 
eight cases the right kidney was involved in twenty-four, the left in 
twenty-two, and both kidneys in two cases. 

Etiology. — These tumors of the kidney may be congenital. This 
was true of 5 cases in a series of 55 collected by Jacobi. The majority 
occur in early childhood. In the collection of 130 cases by Longstreet 
Taylor in which the ages are given, 106 were observed during the first 
five years, and 57 of these in the first two years of life. The sexes were 
about equally affected. 

Symptoms. — The principal symptoms are tumor, hematuria, and 
cachexia. The tumor is usually first noticed. It is in most cases dis- 
covered in the loin, but grows forward toward the median line. Its sur- 
face may be lobulated and irregular or quite smooth; and although solid, 
it is sometimes so soft as to give an obscure sensation of fluctuation. 
It may grow to an enormous size, causing displacement of the liver, 
spleen, intestines, and lungs. The progress of the growth is usually 
rapid, so that from the size of a fist, the tumor may grow in the course 
of five or six months so as nearly to fill the abdomen. By careful palpa- 
tion it will be found — certainly when the tumor is small — that although 
it may be quite freely movable, its attachment is near the lumbar 
spine. 

Hematuria may in rare cases be the first symptom noticed. The 
amount of blood passed is sometimes quite large, but is usually small, and 
blood may be discovered only by the microscope. Pain is rare, and is due 
to localized peritonitis. Constitutional symptoms are usually absent until 
the tumor has attained a. large size, when a cachexia develops and the 
patient wastes steadily. The pressure effects are dyspnea, from compres- 



TUMORS OF THE KIDXEY 



G41 



sion of the lungs; edema of the lower extremities, from pressure upon or 
thrombosis of the vena cava ; vomiting and indigestion from pressure 
upon the stomach and intestines. Tumors of the suprarenale have a 
marked tendency to produce metastaes in the skull. The tumor may re- 
main small and the metastasis may be considered the primary growth. 
Precocious sexual development is often seen with suprarenal tumors. 

The course of the dis- 
ease is steadily from bad to 
worse. The usual duration 
of life in patients not oper- 
ated upon is from three to 
ten months after the tumor 
is large enough to be discov- 
ered. 

Diagnosis. — The impor- 
tant points are, the position 
and attachment of the tu- 
mor, its steady growth and 
solid character, hematuria, 
and the age of the patient 
(under five years). It may 
be confounded with hydro- 
nephrosis, dermoid cyst of 
the ovary, enlargement of 
the spleen, retroperitoneal 
sarcoma, tumors of the 
liver, or even of the abdom- 
inal wall. 

Treatment.— Nothing is 
to be said regarding the 
medical treatment of these 
cases. Unless operated 
upon, they invariably ter- 
minate fatally. Some of 
the results of operation dur- 
ing recent years have been 
encouraging and no ease should be abandoned, do matter how young 
the patient; but a recurrence in a few weeks or months is the usual 
result. 

Benign Tumors. — These are very rare. They are distinguished by 
their slow growth, and by the Tact that the constitutional symptoms are 
mild or wanting. Of the three eases mentioned by Aldibert, one was 
adenoma, one fibroma, and one was fibrocystic. 




Fig. 85. — Sarcoma op the Kidnbt. Child thir- 
teen months old. Weight <>f tumor, seven 

pounds. This patient was followed for sixteen 
years and there was no recurrence. 



642 DISEASES (IF THE tTIOCEXJTAL SYSTEM 

PYELITIS— PYELOCYSTITIS 

Pyelitis is an inflammation of the mucous membrane lining the pel- 
vis of the kidney; cystitis is an inflammation of the mucous membrane 
of the bladder. They may exist separately or together. With pyelitis 
there may be inflammation of the ureter or of the kidney itself (pyelo- 
nephritis), and it may be acute or chronic. It may result in the accu- 
mulation of pus in considerable amount in the pelvis of the kidney 
(pyonephrosis). 

Etiology. — Pyelitis may be secondary to local conditions in the 
genito-urinary tract. It is regularly present with renal calculi. It is 
also frequently associated with congenital malformations of the kidneys 
or ureters, with renal tuberculosis and renal tumors. It may result 
from an extension of inflammation from the tissues surrounding the 
kidney (perinephritis), or from an abscess opening into the pelvis of the 
kidney. Acute pyelitis sometimes occurs as a complication of scarlet or 
typhoid fever, diphtheria, influenza, or pyemia. The organisms found 
in the urine in these cases are the streptococcus, the staphylococcus, the 
tubercle bacillus, the typhoid bacillus, the bacillus pyocyaneus, and very 
rarely the diphtheria bacillus and other bacteria alone or in combination 
with the colon bacillus. 

All these forms, however, are very infrequent compared with the 
form of pyelocystitis which often occurs apparently as a primary affection. 
It may be found, however, in the course of any disease, and frequently 
follows acute disturbances of the gastro-intestinal tract, especially diar- 
rhea. In these cases the evidences of inflammation of the bladder are 
slight or, more frequently, entirely wanting. This form of inflammation 
occurs with by far the greatest frequency in female infants. Male infants 
and older girls occasionally are the subjects of pyelitis. The organism 
present with great uniformity is the colon bacillus, usually alone. Pyo- 
genic cocci are occasionally associated with it. 

The infection has been assumed to be an ascending one, through the 
urethra, chiefly because of the great preponderance of the cases in 
girls; but this is by no means established. That infection may take 
place through the intestinal walls into the genito-urinary tract seems 
probable in view of the frequency with which pyelitis follows diar- 
rhea and by its occasional presence in boys. Infection through the 
blood does not seem to be a likely method, for blood cultures in these 
cases are uniformly negative. Pyelitis is quite frequent in the first two 
years, after that time the number of cases diminishes, but they may be 
found at any age. 

Lesions. — When pyelitis develops from a local cause it is usually uni- 



PYELITIS— PYELOCYSTITIS 643 

lateral; otherwise both sides are involved. In the cases of acute pyelitis 
or pyelocystitis there are the usual appearances of an acute catarrhal 
inflammation of the mucous membrane with congestion, swelling and 
sometimes minute hemorrhages. There may be an accumulation of pus 
of considerable size distending the pelvis and calices (pyonephrosis). 
In most of the severe cases of pyelitis there is also present a certain 
amount of nephritis. This may be merely degeneration or there may be 
collections of polymorphonuclear leucocytes and even the formation of 
numerous small abscesses throughout the parenchyma of the kidney. If 
the condition is one depending upon a calculus or congenital deformity, 
and in all protracted and severe cases, the mucous membrane of the pelvis 
is extensively altered. It may be granular, irregularly thickened and 
present more or less ulceration. In the rare cases of diphtheritic pyelitis 
there is a false membrane. The kidney in all these forms is in- 
volved to a greater or less degree; the extent of the nephritis will 
depend upon the nature of the exciting cause and the duration of the 
process. 

Symptoms, — There are few diseases in which there is such a great 
difference in the severity of the symptoms. In perhaps the majority 
of cases pyelitis is so mild as to cause no symptoms but a slight 
elevation of temperature of one or two degrees, which may be very 
temporary. It would entirely escape detection but for an examination 
of the urine. The pus may be present only in small amount, i. e., four to 
six cells in each microscopical field of nncentrifugalized urine, and for 
only a few days. 

In other cases the symptoms may be quite severe. The history of 
the following case illustrates the main clinical features of acute pyelitis, 
in this instance occurring apparently as a primary disease: 

A previously healthy female infant of eight months was taken sud- 
denly with a chill, followed by a very high fever. The child was ill for 
ten days before the nature of the disease was suspected. During tin- 
time the temperature ranged between 101° and 106° F., touching L05 
nearly every day; but the chill was not repeated. The other constitu- 
tional symptoms were not severe. At the first examination of the urine 
there was found a large amount of \n\^, which on standing was equal to 
one-twelfth of the volume of the urine passed; the reaction \\;i< strongly 
acid. There were no signs of vaginitis or vulvitis, no ardor uritUH 
evidence of local pain either in the bladder or kidney, no abnormal fre- 
quency of micturition, no localized tenderness, and no vomiting. \i 
later examinations there were found in moderate numbers epithelial cells 
from the bladder, and the tubules and pelvis of the kidney, also a few 

•hyaline casts, hut not more albumin than wonhl I xplained by the 

amount of pus. Under no treatmenl except alkaline diuretics, the tern 



644 DISEASES OF THE UROGENITAL SYSTEM 

perature gradually fell to normal, and the pus steadily diminished in 
quantity, and at the end of five weeks had practically disappeared from 
the urine. The, child remained well and entirely free from urinary 
symptoms. 

In some cases there are recurring chills, with wide fluctuations in 
temperature; in others there may be only pyuria, with moderate fever 
and few other constitutional symptoms. The course of the temperature 
is a very irregular one. The fever is seldom continuous, but may be 
interrupted by periods of normal temperature, lasting several days. A 
polymorphonuclear leucocytosis is present. The number of cells is usu- 
ally from 15,000 to 30,000. An agglutination reaction of the colon 
bacillus with the patient's blood can usually be obtained, often in high 
dilution. The duration of the acute attack may be from a few days to 
six or eight weeks, and pus cells may be found microscopically for a 
much longer time. If the disease complicates one of the acute infectious 
diseases, pyuria may be the only symptom. If cystitis is also present 
micturition is frequent, and may be painful. The urine in acute 
pyelocystitis is turbid from the presence of pus, the amount of which 
may be from one to fifty per cent of the volume of the urine. The 
amount of pus varies greatly from day to day. It is often abundant 
when the temperature is low, and almost absent when the temperature 
is high, this fluctuation depending upon the accumulation or the dis- 
charge of the pus. The quantity of urine is generally somewhat dimin- 
ished, and it may be quite scanty. The reaction is usually acid, even 
though the amount of pus is large. Albumin is present in proportion to 
the amount of pus or the degree of nephritis. Red blood-cells are found 
under the microscope in most of the very acute cases, and may be in 
sufficient number to color the urine. The pus cells in recent cases are 
usually well preserved, but in old cases they may be degenerated. 
There are many epithelial cells — conical, fusiform, and irregular cells 
with long tails. There may be renal epithelium and hyaline, granular, 
or epithelial casts, varying in number with the severity of the nephritis. 
In a catheterized specimen the colon bacillus is usually present in pure 
culture. 

There is at times seen a particularly severe form of pyelitis. It 
affects boys as well as girls, usually in the first two years of life. The 
onset is sharp with fever, gastro-intestinal symptoms, occasionally convul- 
sions, and the temperature is often continuously high. The prostration 
is extreme, the loss of appetite marked, and anemia develops very 
rapidly. There is irritability and hyperesthesia, sometimes so marked as 
to suggest meningitis. The urine contains besides the pus, granular casts 
in large numbers. The course is prolonged and the mortality relatively 
high. About 10 per cent of such severe cases prove fatal from exhaus- 



PYELITIS— PYELOCYSTITIS G4.> 

tion, from complications affecting the gastro-iutestinal tract or the 
lungs. Thiemich and Goppert have reported a series of such cases that 
seem to be particularly prevalent in certain localities. We have ourselves 
observed a small number. The severity of the disease is undoubtedly 
due to the fact that the kidneys, as shown by autopsy, are severely in- 
volved. They are really cases of pyelonephritis. 

Pyelitis in older children usually gives more local symptoms. There 
is frequently pain on urination. Pain in the abdomen or loins may 
be marked and there may be tenderness and even muscular rigidity. 
When the right side is involved it may be difficult to exclude appendi- 
citis. 

Pyelitis has a marked tendency to recur. It may do this after a few 
weeks or months or perhaps not for several years. Some children may 
suffer from a number of attacks. Others show few, if any, constitutional 
symptoms, but their urine for a long period may never be free from pus 
cells and there may be exacerbations with fever from time to time for 
many months. 

In pyelitis depending upon congenital malformations, pyuria is usu- 
ally the only symptom, unless pyonephrosis is present. With calculi 
there is an acute or chronic pyelitis; there may be localized pain, ten- 
derness, sometimes a tumor, occasionally hematuria, and perhaps a his- 
tory of renal colic or the passage of gravel. With tuberculosis, there is 
chronic pyuria and the presence of tubercle bacilli in the urine. The 
symptoms of general tuberculosis are commonly associated. If there 
is perinephritis, the inflammation is usually acute, and there are present 
the local symptoms of the original disease. If an abscess opens into the 
pelvis of the kidney, there may be a sudden discharge of pus in large 
quantity with a subsidence of previous local symptoms, including the 
tumor. With neoplasms, both pus and blood may be found in the 
urine, but the latter is more frequent. 

Diagnosis. — The characteristic symptoms of acute pyelitis are chills, 
which may be repeated, high and fluctuating temperature, scanty urine 
containing pus, and occasionally pain and tenderness over the kidneys. 
All of these may be absent, however, except the fever and the pyuria. 
and both the fever and the pyuria may be intermittent. The diagnosis 
of pyelitis is made only by an examination of the urine, which, particu- 
larly in infancy, should never be omitted in cases of obscure high tem- 
perature, whether prolonged or only temporary. If pus is uoi found the 
examination should he repeated several limes. When cystitis is 
ciated, the only additional symptoms may he pain and ether sign 
vesical irritation. These symptoms, with an acid urine containing more 
or less pus and numerous epithelial cells, are sufficient to establish the 
diagnosis of pyelocystitis. If the pus comes from tl pening of an 



646 DISEASES OF THE UROGENITAL SYSTEM 

abscess into the bladder, ureter, or pelvis of the kidney, the local signs 
of such abscess will usually be present. 

Prognosis. — In cases apparently primary, and especially in those due 
to the colon bacillus, the prognosis is good. The danger is chiefly 
from the nephritis which follows or complicates the process and to very 
young and poorly nourished infants who may die from exhaustion as 
the result of gastro-intestinal disturbance. The prognosis in the malig- 
nant form is always doubtful. In cases depending upon local conditions, 
the prognosis will depend upon the nature of the exciting cause. Here, 
also, the principal danger is from nephritis. If calculi are present and 
if pyonephrosis occurs, the patient may die from exhaustion before a 
serious degree of nephritis has developed. 

Treatment. — Water should be given freely, and alkalis up to the 
point of neutralizing the excessive acidity of the urine. A large amount 
of alkali is necessary to accomplish this. Citrate of potash sufficient to 
render the urine alkaline in this condition is apt to cause diarrhea or 
vomiting. It is therefore wise to give not more than five or ten grains of 
this three times a day, but to give bicarbonate of soda from twenty to 
thirty grains every four hours, according to the age of the patient. The 
urine should be kept alkaline for some time after the subsidence of all 
symptoms. The most widely used remedy is hexamethylenamin (uro- 
tropin), which may be given in doses of one or two grains every three 
hours to an infant of a year, and proportionate doses to older children. 
In order that this drug should have an antiseptic action the urine must 
be acid. It is improper, therefore, to combine hexamethylenamin with 
alkalis. We have seen it used in large and small doses in cases of acute 
pyelitis, but have not been convinced of its value. Occasionally pyelitis is 
very resistent to any form of treatment, the exacerbations and remissions 
continuing for many weeks. For such obstinate cases vaccines, preferably 
the autogenous variety, should be tried. Striking benefit has sometimes 
followed their use. If calculi are present or other conditions, such as 
perinephritis, etc., the methods of treatment applicable to these diseases 
are indicated. 

RENAL CALCULI 

Small renal calculi are very common in infancy. In the autopsy 
room we frequently see, on opening the kidneys of young infants, fine 
brown granules in the pelvis and calices, and occasionally a calculus as 
large as a small pea is found. They are usually composed of uric acid. 
Only once in over two thousand autopsies of which we have records, was 
a stone of any considerable size seen in an infant. In this case it was 
an inch in length and half an inch wide. It is surprising that these are 



RENAL CALCULI 647 

so rare, when we consider how very frequently the minute calculi are 
met with. The probable explanation is, that the majority of them are 
dissolved or washed down into the bladder and passed per ureihram 
because of the fluid diet of the first two years. The granular deposits 
are usually lodged in the pelvis of the kidney, and are generally seen 
upon both sides. With the larger collections there is often a slight 
catarrhal pyelitis. 

Symptoms. — The small deposits give no symptoms, and even quite 
large calculi may be found at autopsy when no indication of their pres- 
ence had existed during life, as in the case above mentioned. In some 
cases symptoms are produced which resemble those of renal calculi in 
the adult. In infants less definite symptoms are often passed over as 
merely intestinal colic. 

In well-marked cases in older children there is tenderness, pain local- 
ized over the affected kidney, or radiating to the bladder, the perineum, 
and even the opposite kidney, and there may be irritation and retraction 
of the testicle. The urine may show, especially after exercise, a trace of 
blood; there may be the added symptoms of pyelitis, with some fever, 
localized tenderness, and the appearance in the urine of pus and epi- 
thelial cells from the pelvis of the kidney. 

Eenal colic is produced when a stone of any considerable size passes 
from the kidney to the bladder. It is characterized by symptoms similar 
to those seen in the adult. There are sudden attacks of severe sickening 
pain in the loins, shooting down the thigh or to the testicle. There may 
be vomiting and even collapse. The urine is passed frequently, in small 
quantities, and contains blood. The symptoms quickly subside when 
the stone reaches the bladder. The calculus may sometimes become im- 
pacted in the ureter and give rise to hydronephrosis or pyonephrosis, 
which soon becomes pyelonephritis. 

The existence of small calculi may be suspected from the symptoms 
above mentioned; the diagnosis is made positive by the appearance of 
gravel in the urine. The use of the X-ray is of service in recognizing 
even small calculi. 

Treatment. — The only medical treatment consists in a thud .lid, the 
free use of alkaline mineral waters, and a sufficienl quantity of some 
drug to render the urine alkaline. Such measures will relieve only the 
milder conditions. With larger calculi and more marked Bymptoms, a 
surgical operation should be considered and should he urged in propor- 
tion to the severity of the symptoms and the clearness of the diagnosis. 
If calculous pyelitis exists, it is certain sooner or later to lead to serious 
nephritis, and it is only a question of lime when the kidney will be dis- 
abled. The same is true of hydronephrosis from the impaction of a cal- 
culus in the ureter. Aldibert has collected four cases of nephrectomy in 



648 DISEASES OF THE UROGENITAL SYSTEM 

children for renal calculi in which the kidney was healthy, with three 
recoveries and one death from shock. In nine cases of operation for 
calculous pyonephrosis, there were six recoveries and three deaths. The 
earlier the operation the greater the chances of success, because of the 
better condition of the other kidney. Although the continued use of 
water and the use of drugs may relieve some of the symptoms, it is very 
questionable whether they do more. 



PERINEPHRITIS 

This consists in an inflammation in the cellular tissue surrounding 
the kidney, which may terminate in resolution or in suppuration. It is 
not of very uncommon occurrence. Perinephritis may be secondary to 
suppurative processes in the kidney itself, whether from calculi or tuber- 
culous deposits, or it may be primary. In children the latter is the 
common form. Primary perinephritis is attributed to traumatism, cold, 
or exposure, or it may develop without assignable cause. It usually runs 
an acute or subacute course; very rarely it may be chronic. 

For the clinical picture of this disease we are chiefly indebted to a 
paper by Gibney, who has published a report of twenty-eight cases of 
primary perinephritis in children. The ages of these patients were be- 
tween one and a half and fifteen years, the majority being between three 
and six years. The two sides and the two sexes were about equally 
affected. About one-third of the cases were clearly traceable to trau- 
matism; in the others no adequate exciting cause could be discovered. 
The majority of the cases were referred to the hospital with the diag- 
nosis of hip-joint disease or caries of the spine. Resolution followed in 
twelve of these cases, and sixteen terminated in suppuration. 

When abscess forms, it usually burrows between the lumbar muscles 
and comes to the surface posteriorly near the middle of the iliocostal 
space ; it may burrow forward between the abdominal muscles and point 
just above Poupart's ligament ; very rarely " it may follow the psoas 
muscle and appear at the upper and inner aspect of the thigh, like an 
ordinary psoas abscess ; or it may open into the peritoneal cavity. 

Symptoms. — The onset of acute perinephritis may be quite abrupt, 
with chill, fever, and localized pain ; or it may be gradual, with stiffness 
of the spine, lameness referred to the hip, and deformity due to the con- 
traction of the flexors of the thigh. The pain is usually felt in the loin, 
but may be referred to the groin, to the inner side of the thigh, or to the 
knee. It is often severe, and increased by using the limb. It is in most 
cases accompanied by localized tenderness in the neighborhood of the 
kidney. There is lameness upon the affected side, which may come on 



PERINEPHRITIS G49 

gradually, being sometimes referred to the hip and sometimes to the 
spine. These symptoms often develop slowly in the course of two or 
three weeks. They are usually accompanied by a slight elevation of tem- 
perature. In the most acute cases the temperature is high (102° to 10-t° 
F.), and prostration severe. 

As the disease progresses, fever is a constant symptom, the tempera- 
ture usually varying between 101° and 103° F. There is in most cases 
increasing deformity, and finally the patient may be unable to walk at 
all. On examination at the height of the disease, there is found in a 
typical case a deviation of the spine with the concavity toward the af- 
fected side; the thigh may be held flexed to a right angle; passive exten- 
sion is resisted and causes pain, although all the other movements at the 
hip joint are normal. In the lumbar region there is tenderness, and 
there may be an area of infiltration filling the iliocostal space. At first 
this is only appreciable by percussion, but later a distinct tumor is 
present. In addition to the tumor in the usual region, there is some- 
times one at the upper and inner aspect of the thigh, owing to a bur- 
rowing of pus, and the sacs may communicate. 

Lameness, pain, deformity, and fever sometimes exist for two or 
three weeks before any tumor can be made out. The constitutional 
symptoms are often severe. The size of the abscess is sometimes very 
great. In one case we saw it extend from the spine to the median 
line in front, and from the crest of the ilium nearly to the free border 
of the ribs. The amount of pus varies from a few ounces to two «»i 
three pints. Urinary symptoms are sometimes wanting; at other times 
there is increased frequency of micturition, accompanied by pain from 
an irritation referred to the bladder. The urine may contain pus from ;i 
complicating pyelitis. In only one of Gibney's cases was this present. 
It developed in the fourth week, and the child recovered. 

The duration of the disease in the acute cases varies from three t<» 
eight weeks; in the subacute it may be five or six months. When sup- 
puration occurs the symptoms subside quite rapidly after the pus 1ms 
been evacuated, and recovery is complete. When resolution takes place, 
there is a gradual subsidence of the symptoms, and often Borne stiff] 
of the thigh, with slight lameness for several months. In the series of 
cases above referred to, sixty-five per cent recovered completely in three 
months. 

Diagnosis. — In many cases a diagnosis of hip-joint disease is made, 
but that disease develops more insidiously, is very much more chronic, 
and rarely produces so great deformity in a year a- is often Been in peri- 
nephritis in two or three weeks: abscess is infrequent during the find 
year of the disease. In perinephritis, on the other hand, we ha 
tolerably acute onset, sometimes with chill, fever, marked lameness, and 



650 DISEASES OF THE UROGENITAL SYSTEM 

deformity, developing in two or three weeks; abscess often forms in 
a month, and complete and permanent recovery usually follows after a 
few months at most; the deformity is due solely to flexion of the 
thigh ; all other movements at the hip may be free, and joint tenderness 
is absent. Psoas abscess from Pott's disease may cause deformity, tu- 
mor, and lameness similar to that seen in perinephritis, but on examina- 
tion there is found the angular prominence and other signs of disease 
of the lumbar vertebrae. In cases of doubt the tuberculin test may give 
important aid in diagnosis. 

Prognosis. — Primary perinephritis in children almost invariably ter- 
minates in complete recovery. Of the twenty-eight cases referred to, 
and eight subsequently observed by Gribney, all recovered perfectly. The 
only condition likely to prove fatal is rupture of the abscess into the 
peritoneal cavity. 

Treatment. — The patient should be put to bed and kept as quiet as 
possible throughout the attack. In the early stage, hot fomentations or 
an ice-bag should be applied over the affected side; heat is generally to 
be preferred. Abscesses should be opened early, to prevent burrowing 
and the danger of a possible rupture into the peritoneal cavity. 



CHAPTER III 

DISEASES OF THE GENITAL ORGANS 
MALFORMATIONS 

Adherent Prepuce. — This condition is sometimes called false phimo- 
sis. It is so constantly present that it can hardly be regarded as a 
malformation. It is, however, a condition often needing attention in 
male infants. The prepuce should be retracted so as to expose the glans 
completely. The smegma should then be washed away, the glans covered 
with a drop of oil, and the skin drawn forward. This should be repeated 
daily until there is no disposition to a recurrence of the adhesions. 

Phimosis. — This is such a narrowing of the prepuce that it can not 
be retracted over the glans. The degree of phimosis varies greatly. In 
very rare cases there is no preputial opening. In other cases the orifice 
is so small that no part of the glans can be exposed, and there is obstruc- 
tion to the outflow of urine; but usually a small part of the glans can be 
seen. Phimosis may be complicated by an elongated prepuce (hyper- 
trophic phimosis), and the elongation may exist without any narrowing 
of the orifice, although this is usually present to some degree. 



MALFORMATIONS 651 

The presence of phimosis makes cleanliness impossible in many cases, 
and want of cleanliness leads to infection and to balanitis. This is quite 
frequent, even in infants. It may be complicated by urethritis, and even 
by cystitis. Another consequence of the straining induced by phimosis 
is hernia, which may be either inguinal or umbilical. To cure the hernia 
is often impossible, unless the phimosis is relieved. The list of reflex 
phenomena which have been ascribed to phimosis is a long one. There 
has been a disposition on the part of some to attribute nearly all the 
nervous disturbances of boyhood to phimosis, and an exaggerated impor- 
tance has certainly been attached to this condition. A very marked 
degree of phimosis often exists in children without producing any symp- 
toms. That phimosis is an etiological factor in many neuroses is cer- 
tainly to be doubted. Our experience with circumcision as a cure for 
such conditions has been very unsatisfactory. When cleanliness is im- 
possible the irritation and resulting pruritis may cause frequent priap- 
ism and may at times encourage masturbation. Phimosis may rarely 
lead to vesical spasm and retention of urine, but more frequently to noc- 
turnal incontinence. 

Treatment. — Phimosis should receive attention in infancy. Often 
very little treatment is needed. When there is a very long prepuce 
with phimosis, the operation of circumcision should be done, even when 
the degree of phimosis is slight. Many cases of phimosis in which the 
prepuce is not long can be relieved by stretching. If no part of the glans 
can be exposed, the simplest plan is to slit up the dorsum of the prepuce, 
with a pair of scissors and break up the adhesions. The corners of the 
flaps thus made can then be snipped off and one stitch inserted on either 
side. To promote cleanliness in older boys or in cases of hernia 
or prolapse and when phimosis is present, circumcision should he per- 
formed. 

Hypospadias. — In this condition the urethra is not continued to the 
tip of the penis, but opens on the inferior surface some distance back, 
being represented in front of this only by a shallow furrow. In more 
severe cases there is a deep fissure which divides the scrotum, and some- 
times even the perineum. Into this fissure the urethra opens. This is a 
condition likely to be mistaken for that of hermaphrodism, especially 
as the testicles are frequently in the abdominal cavity. 

Epispadias. — This is a condition in which the urethra opens on the 
dorsal surface of the penis. Tt is much less frequent than hypospadias. 
There may be simply a division of the glans, or the fissure may extend 
the whole length of the organ and be complicated by exstrophy of the 
bladder. 

Exstrophy of the Bladder.- In the complete form there ie a median 
fissure from the umbilicus to the tip of the penis. It includes the an- 



652 DISEASES OF THE UROGENITAL SYSTEM 

terior abdominal wall, the pelvic bones, and the urethra. The bones are 
entirely separated at the symphysis, or connected behind the bladder by 
a fibrous band. The hypogastric region is occupied by a red, mucous 
surface, slightly corrugated, which is all there is of the bladder. In the 
lower lateral portions of the red mucous membrane two slightly rounded 
elevations are seen, from which urine oozes. These are the openings of 
the ureters. The penis is short, and presents a shallow furrow on its 
dorsal surface. The testes are often in the abdominal cavity. 

An analogous deformity is sometimes seen in girls. There is a division 
of the clitoris and the labia minora and majora. The fissure may be so 
deep as to reach nearly to the anus. The vagina is usually absent. The 
rectum may open into the prolapsed bladder. 

All these deformities are compatible with long life. In exstrophy of 
the bladder, whether complete or partial, patients are a nuisance to them- 
selves and to all about them. It is almost impossible to prevent the 
clothing from being soaked with urine, which gives everything connected 
with the patient a strong ammoniacal odor. The skin is often excoriated. 
Operation for the relief of these cases should always be undertaken. 
The operation to be recommended is the transplantation of the ureters 
into some part of the large intestine, usually the rectum. The results 
are often most surprising. The rectum soon becomes tolerant of the 
urine, holds it for hours without difficulty and evacuates it without dis- 
comfort. Ascending infection of the kidney seldom occurs. 

Undescended Testicle — Cryptorchidism. — In fetal life the testes are 
situated in the abdominal cavity below the kidneys. They usually descend 
into the scrotum during the ninth month, but in children born at term 
the testicles may be in trie inguinal canal, or even in the abdomen. The 
former condition is quite frequent, being present in fully ten per cent of 
all male children. In most of these the descent takes place without dif- 
ficulty during the first weeks of life, and causes no symptoms. In others 
the condition may persist. Spontaneous descent may take place at any 
time before puberty, the chances, however, steadily lessening as age ad- 
vances. When in the inguinal canal, on account of its exposed situation, 
the testicle may be injured, or become painful and tender as puberty 
approaches. In any abnormal position it probably will not develop prop- 
erly, and may remain without function, but interference with the devel- 
opment of the body is rare. Hernia is a frequent complication. 

When in the inguinal canal, descent of the testicle may sometimes be 
facilitated by manipulation. If the condition is unilateral, operation is 
unnecessary except for relief of pain. If it is double, operation should 
be performed before puberty, preferably from the ninth to the eleventh 
year. Transplantation into the scrotum is at this time simple, and usu- 
ally successful. Should pain be persistent, and transplantation impossi- 



DISEASES OF THE MALE GENITALS 653 

ble, the testicle may be replaced in the abdominal cavity. Removal is 
indicated only when degeneration has taken place. 

With the exceptions already mentioned, deformities of the female 
genitals belong rather to gynecology than to pediatrics, since they are 
chiefly of the internal organs, and do not usually give symptoms before 
puberty. 

DISEASES OF THE MALE GENITALS 

Balanitis. — Balanitis, or inflammation of the prepuce, is one of the 
results of phimosis. It may follow decomposition of the smegma, infec- 
tion of the mucous membrane, injury, or masturbation. The parts are 
swollen, edematous, red, painful, and sometimes bathed in pus. Re- 
traction of the prepuce is impossible. Under proper treatment the in- 
flammation usually subsides in two or three days, but there may be some 
discharge for a considerable time. Abscess may follow, and even gan- 
grene of the prepuce. The most severe cases are likely to be complicated 
by anterior urethritis. We have frequently seen erysipelas start from 
balanitis, and occasionally diphtheria occurs here. 

The object of treatment is to remove the irritating and infectious 
material lodged beneath the foreskin. This may be quite difficult. It is 
best accomplished by syringing with a 1-5,000 bichlorid solution, and 
the constant application of a wet antiseptic dressing. Ice is often useful 
when the edema is great. It is sometimes necessary to slit up the 
prepuce before the parts can be thoroughly cleansed, and in severe cases 
this is often the quickest method of cure. Circumcision should not be 
done during an attack. 

Urethritis. — This, like the same disease in females, may be simple 
or specific. Both forms are much less frequent in little boys than in the 
other sex. In simple urethritis the inflammation usually affects only the 
anterior part of the canal, the fossa navicularis. There is a slighi dis- 
charge of pus, and sometimes pain on micturition. The most frequenl 
cause is want of cleanliness. 

Gonococcus inflammation is more common. This occurs even in in- 
fants, but most of the cases are in those over seven years old. The usual 
cause is direct contagion. The symptoms are more severe than in the 
simple form, and resemble the same disease in the adult, with the ex- 
ception that constitutional symptoms are usually absent A microscopical 
examination of the discharge is the only positive means <»f diagnosis 
between the two varieties. In these cases it reveals the gonococcus in 
great numbers. Conjunctivitis and arthritis are seen as complical 
just as in the female. Epididymitis i- rare, hut balanitis ami bubo 
not infrequent. Poynter has reported a case in a boy of three years, who. 



654 DISEASES OF THE UROGENITAL SYSTEM 

when five years old, required treatment for a urethral stricture. He was 
infected by a nurse. 

The first thing in the treatment is always to keep the parts covered, 
otherwise the infection may be carried by the hands to other mucous 
membranes, usually the conjunctiva. In other respects the treatment 
is the same as in the adult. 

Hydrocele. — Hydrocele consists in an accumulation of serum in some 
part of the serous pouch brought down by the testicle in its descent. In 
infants it is usually due to the imperfect closure of this pouch at some 
point, where a fluid accumulation occurs. Four varieties of hydrocele 
are met with in young children. 

1. Congenital Hydrocele. — In this the condition is a congenital one, 
although the tumor is not necessarily present at birth. The tunica vagi- 
nalis communicates with the general peritoneal cavity. There is present 
an elongated tumor, extending from the bottom of the scrotum through- 
out the whole length of the cord. The tumor is reducible, sometimes 
spontaneously by position, sometimes, when the opening is smaller, only 
by pressure. It reduces slowly, without gurgling, never going back en 
masse like a hernia. The tumor is translucent, and is flat on percussion. 
The testicle is above and posterior, and usually indistinctly felt. Con- 
genital hydrocele may be complicated by hernia. 

2. Hydrocele of the Tunica Vaginalis with the Canal Closed. — In 
this form the accumulation of fluid is in the scrotum, communication 
with the peritoneal cavity having been entirely cut oif by the complete 
obliteration of this pouch in the canal in the normal way. This is one of 
the most frequent forms. It gives rise to an oval or pear-shaped tumor, 
quite tense and firm, usually about two inches in length. The cord is 
distinctly felt above it, the testicle is behind and somewhat above it, and 
not always felt very distinctly. This variety gives translucency and the 
usual elastic feeling of a hydrocele. 

3. Hydrocele of the Cord. — This is one of the rare forms. The serous 
pouch which accompanies the spermatic cord is open above, and com- 
municates with the peritoneal cavity; but below it is closed. The 
scrotum is normal, and the testicle is in its usual position. The tumor 
is small, elongated, reducible, and entirely above the scrotum. Usually 
it stops at some point in the inguinal canal. This hydrocele also may 
be completed by hernia. The diagnostic points are the same as in the 
form first mentioned. 

4. Encysted Hydrocele of the Cord. — The peritoneal pouch of the 
cord in this variety is closed for some distance above, and again below, 
but somewhere in its course it is open, and here the fluid accumulates in 
the form of a cyst. When small it resembles an undescended testicle; 
but on examination this organ is found below and in its normal position. 



VAGINITIS 655 

When in the canal, it is often mistaken for a lymph gland, sometimes 
for a small hernia. The tumor is usually about the size of an almond. 
Tt is elastic and irreducible, and translucent like the other varieties. 

Treatment of Hydrocele. — In the congenital form the application of 
a truss will sometimes cause obliteration of the canal, so as to shut off 
the hydrocele sac from the general peritoneal cavity. It is subsequently 
managed like an ordinary hydrocele of the tunica vaginalis. In infants 
and young children it is rare that active operative measures are called 
for in any variety of hydrocele, as these usually tend to disappear spon- 
taneously in the course of a few months. Iodin may be applied locally 
over a hydrocele of the cord, but should not be applied to the scrotum. 
Some cases are cured by a simple puncture with a needle, allowing t In- 
fluid to drain off into the cellular tissue of the scrotum from which it 
is absorbed; others by a single aspiration with a hypodermic syringe. 
It is seldom necessary to resort to the injection of irritants like iodin 
or carbolic acid, but they may be used if the fluid returns after repeated 
aspirations. 

DISEASES OF THE FEMALE GENITALS 
VAGINITIS 

This is a catarrhal inflammation usually affecting only the vaginal 
mucous membrane, but may involve the urethra, bladder, and, in older 
girls, the lining membrane of the uterus, the tubes, and even the peri- 
toneum. It may be either simple or specific (gonorrheal) ; the purulent 
form is almost invariably specific. 

Simple Vaginal Catarrh. — This may be seen at any age, even in in- 
fancy, but is most frequent after the second year. It occurs especially 
in girls suffering from malnutrition and anemia, and whose personal 
cleanliness is neglected. It may follow any of the in feel ions diseases, 
particularly measles. It sometimes complicates varicella with a local 
lesion in the vagina. It may be traumatic, as from attempted rape or 
the introduction of foreign bodies. Other causes are pinworma and 
scabies. It is sometimes the cause, sometimes the result of masturbation. 

The disease generally begins as a subacute catarrhal inflammation, 
the discharge being the first, and in mild cases the only symptom. Ii ifl 
of a white or yellowish-white color and not very abundant. If the 
parts are not kept clean the odor of the discharge is quite foul. I u Revere 
cases the discharge is abundant, and may excoriate the skin of the labia 
and thighs. The mucous membrane is swollen and red, hut there is 
only a moderate secretion. Microscopical examination of the discha 
shows bacteria in large numbers and of many varieties, bui they air 
chiefly the ordinary cocci. Wi(h proper treatment and in children who 



656 DISEASES OF THE UROGENITAL SYSTEM 

are in good general condition, the disease usually lasts but a few weeks. 
Under unfavorable conditions a leucorrheal discharge may continue for a 
much longer time. 

Cases of simple vaginal catarrh should be irrigated daily with a warm 
saturated solution of boric acid or 1 to 5,000 bichlorid. Cleanliness 
should be secured by frequent bathing and the skin protected by oint- 
ments. In more severe cases, astringent injections, such as sulphate 
of zinc and tannic acid (of each one dram to a pint of water) should be 
used. The general health should be built up by iron, cod-liver oil, and 
other tonics. 

Gonococcus Vaginitis. — This disease once considered rare in children 
has been shown to be exceedingly common in girls of all ages, even in 
young infants. Its control has become a social problem of much im- 
portance, and one that is beset with peculiar difficulties. Gonococcus 
vaginitis is an especial scourge in institutions, in homes and asylums 
for older girls, and in those for infants as well; also in hospitals, par- 
ticularly those in which prolonged residence is necessary. Routine ex- 
aminations made in large institutions for children have revealed the 
presence of this disease, often, it is true, in a mild form, in from 2 
to 10 per cent of the female inmates. In a single year, of 1,200 children 
under three years, chiefly infants, applying for admission to the Babies' 
Hospital, 63, nearly one per cent of the females, were found to be suf- 
fering from gonococcus vaginitis. Epidemics in institutions are fre- 
quent and very difficult to control. Before means of prevention were so 
well understood as they are now, four epidemics were observed in the 
Babies' Hospital in five years, with 273 cases. 1 Day nurseries are an- 
other common agency of spreading the disease. 

But gonococcus vaginitis is by no means confined to the classes men- 
tioned. In out-patient practice and among the poor who live in tene- 
ments, it is common in girls of the school age who have never been ex- 
posed in institutions. Even in private practice among the well-to-do, 
cases are not very rare. 

The ultimate source of infection in children with this disease in most 
cases is undoubtedly contact in the home with adults suffering from it. 
In several series of cases carefully investigated fully one-third have been 
definitely traced to a mother or sister suffering from the disease, with 
whom the young child has slept. In the home, infection may also take 
place by baths, clothing, dirty toilets, etc. Among companions infection 
may take place by manual contact, masturbation being frequent among 
infected persons; in schools and other public places it may unquestion- 
ably be spread by the toilet seat. Criminal assault is a rare cause among 
children. 

1 "Gonococcus Infections in Institutions," N. Y. Medical Journal, March, 1905. 



VAGINITIS 657 

In institutions for infants and young children the disease is most 
often acquired through the medium of diapers. Other possible sources 
of contagion are towels, sponges, wash-cloths, clothing, bed linen, ther- 
mometers, syringes, bath tubs, and bath water. Even when the most 
careful attention is given to all these matters we have sometimes seen 
ward epidemics continue. The most probable explanation of such a con- 
dition is that the disease is spread by the hands of the nurse in washing, 
dressing, or the changing of napkins. In such cases nurses as well as 
infected children must be quarantined. In some instances it is impos- 
sible to trace the mode of spreading. 

The susceptibility of the vaginal mucous membrane to gonococcus 
infection is very great in young children, which in part accounts Eor the 
prevalence of this disease. A further reason for the frequency of infec- 
tion is probably to be found in the want of protection of the mucous mem- 
brane owing to the small size of the labiae. Vaginitis should not in 
early life be regarded as a venereal disease. 

The constant presence in cases of vaginitis in children of an organism 
which morphologically and culturally is identical with the gonococcus 
found in acute inflammations in the adult, has led to the belief that 
the two diseases were identical. But the mildness of the local inflamma- 
tion in the great majority of the cases in young children, the absence 
of constitutional symptoms and of serious complications has led to the 
suspicion that there might be important differences in the infecting agent 
in the two groups of cases. Pearce, of the Rockefeller Institute, has re- 
cently shown by immunological tests (agglutination and complement fixa- 
tion) that the type of organism in the two groups is quite distinct. Not 
a single exception was found in the cases studied. The in frequency of 
ophthalmia as a complication in little children has often been noted. 
In our own experience it has been rare. In this connection it is inter- 
esting to note that in cases of ophthalmia in infants studied by Pearce 
the organism corresponded in every instance to the adult type. Should 
these differences in type prove to be the rule, we may find that gonococ- 
cus vaginitis in young children, though a most troublesome condition, is 
not so serious a matter as many have been inclined to regard it. 

Symptoms. — In the mild cases the disease is limited to the mucous 
membrane of the vagina. There is a moderate yellow discharge, smears 
of which show pus cells and gonococci. There is very little redness of the 
mucous membrane and no local symptoms of discomfort. In the more 
severe form the discharge is copious, often thick and of a yellowish- 
green color. It may be tinged with blood from slight erosions. It 
causes excoriation of the labiae and inner surface of the thighfi 
turition may be frequent and painful owing to the involvement of the 
urethra. If a small speculum is introduced and the parts examined with 



658 DISEASES OF THE UROGENITAL SYSTEM 

a good light, the extent and severity of the disease can he determined. 
It is usually seen that the inflammation is a general one affecting the 
urethra, vagina, hymen, and the cervix uteri. The parts are intensely 
congested, granular in appearance and the purulent discharge may be 
seen coming from the cervix. With these severe local symptoms there 
may be in the acute stage some constitutional symptoms as in the adult. 
But the cases seen in little children are seldom of this severe form. 

In the most severe cases, usually seen in girls past the age of six 
or seven years, the inflammation may involve not only the cervix, but 
the entire endometrium; it may extend to the Fallopian tubes and even 
the pelvic peritoneum. Cases of this severity may be seen, though very 
rarely, in children of only three or four years. We have never met 
with them in infants. Swelling and suppuration of the inguinal glands 
are very rare. Other complications are conjunctivitis, arthritis, endo- or 
pericarditis, meningitis, and proctitis. Conjunctivitis is surprisingly in- 
frequent in very young patients. Arthritis is usually multiple and in- 
volves especially the small joints of the fingers, toes, wrists, or ankles, 
but the large joints may also be attacked. Symptoms of pyemia are 
usually associated. These cases are more fully considered in the chapter 
on Acute Arthritis in Infants. The diagnosis in all the complicating 
conditions rests upon the presence of the gonococcus. Masturbation 
is not uncommon in these cases and occasionally it is associated with 
sexual precocity. 

Diagnosis. — A positive diagnosis between simple and gonococcus 
vaginitis can be made with certainty only by a microscopical examination 
of the discharge, though in default of such examination an abundant 
purulent discharge may be assumed to be due to the gonococcus. In 
simple catarrh the discharge is made up of epithelial and pus cells with 
quite a wide variety of bacterial forms, chiefly cocci and bacilli, occa- 
sionally a few diplococci. In gonococcus vaginitis the gonococci are 
found in large numbers, and are usually the only bacteria present. 
To be diagnostic, they should be demonstrated within the pus cells 
as well as outside them. The gonococcus decolorizes when stained by 
Gram's method, which fact distinguishes it from the other organisms 
likely to be present in the vagina. The staining is quite as diagnostic 
as the cultural characteristics of this organism. Cases of vaginitis arc 
to be regarded as suspicious if pus is found and few organisms are de- 
tected; in such conditions subsequent examination usually reveals the 
gonococcus. In our hospital experience the gonococcus cases have out- 
numbered the simple purulent forms, fully twenty to one. 

Since the diagnosis rests upon the microscopical examination of 
smears made from the vaginal secretion, the manner in which smears 
are taken is important. A moist swab or a platinum loop may be used, 



VAGINITIS 659 

the latter being preferred, or a few drops of a 1 to 10,000 bichlorid 
solution may be instilled into the vagina and withdrawn with a pipette : 
after evaporating the fluid the residue is stained. The smear should be 
taken far inside the vagina, preferably through a small speculum, such 
as a female urethroscope. Unless these precautious are used a good inan\ 
cases will be missed, especially since smears from the cervix are some- 
times positive when those taken from the vagina may be negative. 
When properly made and examined by an experienced person the results 
of the examination may be relied upon for diagnosis. In a certain 
proportion of the cases, usually those of a severe type with constitutional 
symptoms, a positive result is obtained by the complement fixation test. 
This reaction is also at times of value in establishing the fact of cure. 
In cases complicated by multiple arthritis the gonococcus is usually 
found by blood cultures, even though the vaginal smears may be 
negative. 

Prophylaxis. — The problem of controlling this disease is a difficull 
one owing to its great frequency, its extremely contagious character, its 
protracted course, and the unsatisfactory results of treatment. Edu- 
cational measures come first in importance. Mothers, nurses, social 
workers, matrons of institutions, hospital and school authorities should 
all be made acquainted with the prevalence of the disease and the means 
by which it is usually spread. The attitude of the public toward the 
problem would be more intelligent if the idea that vaginitis in young 
children is a venereal disease could be gotten rid of. Even girls them- 
selves who are likely to be exposed, should be instructed as to the 
dangers of infection and the means of its avoidance. The importance 
of proper cleansing of the genitalia is the first lesson to he taught. In 
the home, essential measures of prevention are that an infected person 
should sleep alone, should wear a vulvar pad of such a character that 
it can be destroyed, that sheets and clothing should he washed separately 
from those of the household, and that especial care he used about both 
bath tubs and bath water and the toilet seat. In the school the greatesi 
danger is probably from the common toilet; scrupulous cleanliness of 
this should be secured; only the U-shaped toilet seat should he used, not 
merely in schools but in all public places. Another chief source of in- 
fection being contact with infected companions, this should he limited bo 
far as possible. To make the disease a reportable one and exclude 
infected children from public schools does not seem a practicable 
measure, since this would involve the examination of Bmears from all 
the girls attending school. The importance of the disease does not 
justify such radical measures. 

It is in institutions foe children thai the problem of prevention 
is most difficult and also most important. In all day nurseries, lion 



660 DISEASES OF THE UROGENITAL SYSTEM 

pitals and homes similar means mnst be employed, viz., the examination 
of vaginal smears from every child on admission should be a matter 
of routine; cases showing the gonococcus should not be received into 
the same ward or dormitory with others, and even cases showing only 
pus cells but no gonococci should be quarantined. In hospitals for 
children, routine smears should be taken from all female children at 
least once a week. In no other way is it possible to recognize cases 
early and prevent ward epidemics. 

The attendants, both day and night nurses, as well as the affected 
children, should be quarantined. Napkins, underclothing, and sheets 
from the beds of such patients, also their towels and wash-cloths, should 
not go into the common laundry, but should be first soaked in a strong 
solution of carbolic acid, and afterward boiled. In wards or institutions 
where cases have occurred, washable napkins should be discontinued and 
old muslin and absorbent cotton substituted. These are to be destroyed 
after using. All articles connected with the children's toilet, also 
syringes, thermometers, etc., should be carefully disinfected. But often 
this is not enough. Separate articles should be furnished for each child. 
The essential measure is a prompt recognition and isolation of the first 
case in the hospital. The danger to life in this disease is not great, and 
is from the serious complications mentioned above, all of which are very 
infrequent in young children. In very many cases, however, the disease 
lasts for years even in spite of treatment and the question of the ulti- 
mate damage to the general health or, what is more important, to the 
organs involved must be considered. At present we have not enough 
knowledge to warrant positive statements upon this point. It is pos- 
sible that many of these protracted cases ultimately recover spontaneously, 
or that after long continuance of the disease the organisms present have 
such a low virulence that their capacity for injury is very slight indeed. 
The disease is not a new one and it is very prevalent; were the ulti- 
mate dangers as great as some have asserted more evidence of this 
would exist than now appears to be the case. Facts now at hand do 
not justify the belief that the ultimate dangers from vaginitis in 
children are great, or in any way comparable to acute gonococcus 
vaginitis acquired in adult life. Some reason for this may be found 
in the biological difference in the gonococci from adult and infantile 
cases which has been already referred to. 

Treatment. — On account of its very chronic character and its preva- 
lence chiefly among the poor, most cases of vaginitis must be treated 
in out-patient clinics. Special clinics for such cases should be estab- 
lished in every large city, attached to which should be a visiting nurse 
who should see that proper treatment is carried out in the home. To 
be at all successful local treatment must be thoroughly carried out by a 



VAGINITIS C01 

physician and for a long period. The first essential is local cleanliness 
which must be secured by bathing the external organs twice a dav with a 
solution of boric acid or some similar preparation. In spite of the 
obvious objections to their use, irrigations are probably the most valuable 
of the local measures we possess. These should be made daily if possible 
and through a catheter whose tip is carried well into the vagina. Boric 
acid solution or permanganate of potash 1-2,000 to 1-5,000, ichthyol 
1-1.000, or bichlorid 1-10,000 may be used. Following the irrigation 
local applications should be made every second or third day of nitrate 
of silver 10 per cent, or argyrol 20 per cent strength. These should 
be made with an applicator through some sort of a speculum — the female 
urethroscope answers very well for small patients — and the child kept 
upon the back with the thighs in contact for a short time. If the cervix 
is involved local applications made in the manner indicated are essential 
if anything is to be accomplished. 

Eegarding the value of vaccines there is still much difference of 
opinion. Some writers have reported excellent results while others with 
considerable experience have seen little benefit from their use. Our own 
experience is that their effects are very uncertain ; that, while in some 
instances striking improvement has been seen, in the great majority of 
cases this does not occur. The best results are seen in the most recent 
cases. Eegarding the value of vaccines in some of the complications, 
especially arthritis and general sepsis, there can be little question. The 
autogenous appear to have no advantage over stock vaccines. The 
dosage of vaccines is still empirical. It is customary to give from 50,000,- 
000 to 75,000,000 as an initial dose, to repeat every five or six days. 
gradually increasing this to 100,000,000. If no improvement is seen 
after six or eight injections, their continuance is useless. In connec- 
tion with the administration of vaccines careful bathing of the external 
organs should be combined, but irrigations may be omitted. Because 
of the favorable results sometimes seen, the use of vaccines is to be 
advised in all recent acute cases of the severe form. The prolonged 
use of irrigations has serious objections in girls of seven or eight years 
or older, in that it tends to develop sexual consciousness and may lead 
to masturbation. 

On the whole, it must be stated that the results of treatment in 
cases which have reached the chronic stage by any measures ye1 propo 
are very unsatisfactory, largely owing to the difficulty of controlling the 
patients for the tedious period of local treatment which is necessary. 

Relapses are exceedingly common even in cases in which there has 
been no discharge for weeks or even months. Of twenty-six cases care- 
fully followed up by Spaulding and subjected to thorough treatment. 
all but two relapsed after variable period- from one t«. six months. 



662 DISEASES OF THE UROGENITAL SYSTEM 

That such cases are reinfections seems improbable. It would rather 
appear that the disease may have long periods of latency and recrudes- 
cence for an indefinite time. It is therefore difficult to say when a 
given case is actually cured. Under most conditions one is safe in 
pronouncing a case cured when there has been no discharge for three 
months after the discontinuance of special treatment, and when smears 
from the deeper parts continue to be negative. 



GANGRENOUS VULVITIS (NOMA) 

This is the same process as that seen in the mouth and known as 
cancrum oris. It usually follows one of the infectious diseases, most 
frequently measles, occurring in patients whose general vitality has been 
greatly reduced. There is first noticed a tense, brawny induration, the 
skin being shiny and swollen over a circumscribed area. In the center 
of this there soon appears, usually upon one of the labia majora, a dark, 
circumscribed spot. Day by day the gangrenous area advances, preceded 
by the induration. It may involve the whole labium, extending even to 
the mons veneris and the perineum. These cases are generally fatal. 
If recovery takes place, it is with considerable deformity of the parts in 
consequence of the extensive sloughing and cicatrization. As sequelae, 
there may be fistulae, stenosis, or atresia of the vagina. The only radical 
treatment is early excision, and the application of the actual cautery, 
carbolic or nitric acid. 



CHAPTEE IV 
DISEASES OF THE BLADDER 

ENURESIS 

(Incontinence of Urine; Bed-wetting) 

Enuresis may be due to some malformation of the genital tract, such 
as an abnormal opening of the bladder into the vagina, to extroversion 
of the bladder, or to the persistence of the urachus; in the latter case 
the urine is discharged from the umbilicus. It also occurs in organic 
diseases of the central nervous system, such as idiocy, cerebral palsy, 
acute meningitis, tumors of the brain, certain forms of myelitis, spina 
bifida occulta, and in injuries of the cord. In many of these conditions 
there is associated incontinence of feces. Both of the groups of cases 
mentioned are quite distinct from the ordinary form of incontinence of 



ENURESIS 663 

urine which is seen in childhood. The latter is the only variety which 
will he considered here. 

It is in many cases possible to teach infants to control the evacuation 
of the bladder before the end of the first year; usually, however, control 
is not acquired even during waking hours until some tunc during the 
second year, and in some healthy infants not before the end of the second 
year. The time depends very much upon the training, [f a child during 
its third year can not control the evacuation of the bladder during its 
waking hours, incontinence may be said to exist. 

Etiology. — Incontinence of urine may be due to a continuance of the 
infantile condition, to anything which increases the irritability of the 
spinal center, or which interferes with the cerebral control over this 
center, or to anything which increases the irritability of the terminal 
filaments of the vesical nerves or of those in the neighborhood. The 
causes of incontinence thus may be in the central nervous system, in the 
urine, in the bladder, or in any of the adjacent organs. 

The causes relating to the central nervous system are in the main 
those of the other neuroses of childhood; these are anemia, malnutrition. 
an inherited nervous constitution, or a condition of extreme nervousness 
or neurasthenia, the result of the child's surroundings. In such cases 
incontinence is often associated with chorea, epilepsy, hysteria, headaches. 
neuralgia, and other nervous symptoms. In these conditions there is 
assumed to be not only an increased irritability of the nerve centers, hut 
also of the peripheral nerves, accompanied l>\ loss of tone of the vesical 
sphincter. A similar condition may exist with almost any form of acute 
illness, this usually, however, being only temporary. 

Incontinence may be caused either by a highly acid, concentrated 
urine when an insufficient amount of fluid is taken, or by the opposite 
condition, when owing to the drinking of a large quantity of water, often 
only a matter of habit, the amount of urine is very -really increased and 
passed at frequent intervals. 

In the bladder itself, cystitis and vesical calculus, although infre- 
quent, should not be overlooked as possible causes. In a few cases, where 
incontinence has existed a long time, the bladder becomes bo contracted 
that it will hold only an ounce or two of urine. This condition, ah hough 
not the primary cause of enuresis, may be enough to continue it. 

Local irritation in the neighboring organs may he due to adherent 
prepuce, balanitis, phimosis, or to a narrow meatus. All of these condi- 
tions are frequently associated with incontinence. Rectal irritation may 
be due to pinworms, anal fissure, or rectal polypus; ami vaginal irrita- 
tion to vulvovaginitis or adherent clitoris; hut these are rarely tl nly 

cause. Often there is incontinence as the result of a combination of 
era! causes, no one of which alone would have been sufficient i" produce 



GG4 DISEASES OF THE UROGENITAL SYSTEM 

it. In many cases heredity seems to be a factor of some importance, 
parents often having suffered in their childhood from the same condi- 
tion ; quite frequently two and sometimes even three children in the same 
family are affected. In many cases the condition seems to be mainly 
the result of habit, and in all cases habit is a potent factor in continuing 
the incontinence, sometimes after the original exciting cause has been 
removed. Frequently no adequate cause can be found. Both sexes 
are about equally liable to enuresis; it may be seen in all ages up to 
puberty and even to adult life. 

Symptoms. — Enuresis may be nocturnal or diurnal, or both. Of 184 
cases, 73 were nocturnal, 9 diurnal, and 102 were both nocturnal and 
diurnal. Cases differ greatly in severity. Incontinence may be habitual,' 
occurring every night, often several times during the night, and fre- 
quently during the day ; or it may be only occasional under the influence 
of some special exciting cause, when it continues a few days or weeks 
until the cause is removed. In a considerable number of cases, the condi- 
tion lasts from infancy until the sixth or seventh year. It may even con- 
tinue until puberty ; but it generally ceases at that period, unless its cause 
is mechanical or depends upon some organic disease of the brain or cord. 
In ordinary enuresis there is never dribbling of the urine, but usually a 
contraction of the walls of the bladder follows almost immediately upon 
the desire before the patient can make his wants known or reach a con- 
venient place for micturition. At night the same thing may occur 
without wakening the child, the contraction being of purely reflex 
origin. 

Prognosis. — The condition is usually hopeless when it depends upon 
organic disease of the brain and cord ; also in cases due to malformation, 
unless these are amenable to surgical treatment. In the ordinary cases 
seen, the prognosis depends upon the age of the child, the duration of the 
symptom, and the nature of the exciting cause. In children of from 
three to five years a cure can in most cases be accomplished with proper 
management. Those who are older are much less amenable to treatment, 
especially if the condition has persisted since infancy; but if the incon- 
tinence has begun after seven or eight years of age and lasted but a few 
weeks or months, the outlook is much more encouraging. There are, 
however, some cases in which no other cause than habit can be discovered 
which resist all treatment, the condition finally ceasing spontaneously 
about puberty; rarely does it continue beyond this period. 

Treatment. — The first indication is to remove the cause, when one 
can be found. If there are preputial adhesions, they should be broken 
up and irritating smegma removed. If phimosis is present, it should be 
relieved by circumcision. If stone in the bladder is suspected, as it 
should be when the incontinence is worse by day and accompanied by 



E^"URESIS 665 

straining and painful spasm of the bladder, the patient should be 
sounded for stone. Pin worms in the rectum should receive the appro- 
priate treatment by injections. While the local conditions mentioned 
should always be attended to, the fact remains that few cases are cured 
simply by relieving them, except those due to vesical calculi. The ex- 
planation of this is that habit is the important factor in keeping up 
incontinence. 

A concentrated urine of high acidity with deposits of uric acid is 
an indication for alkalis and the free use of all fluids, especially water. 
On the other hand, when there is passed a large quantity of urine of 
low specific gravity, the amount of water and other fluids should be 
greatly restricted. During the night water should be forbidden. In these 
cases the incontinence is often simply the result of the polyuria, which 
in turn depends upon polydipsia. 

In most cases the condition is purely a habit, often associated with 
other habits which indicate an unstable or highly susceptible nervous 
system. It is therefore of the greatest importance that a proper general 
regime should be instituted. Care should be taken to secure for the 
child a simple, natural life, with no overtaxing of the nervous system at 
home or in school. Every cause of unnatural excitement should be 
avoided. Early hours and plenty of sleep should be insisted upon. Cer- 
tain articles of diet are to be avoided, and coffee, tea, and beer should 
be absolutely prohibited. Sweets and all highly seasoned food should 
be very sparingly allowed, or not at all. The exclusion of meat from 
the diet seems to us to be of no special advantage. Measures directed 
toward improving the general muscular and nervous tone are of the 
greatest importance. Anemia, malnutrition, indigestion, and constipa- 
tion should each receive careful attention. 

Punishments, whether corporal or otherwise, do little good, and 
usually they are harmful. Eewards are sometimes more efficacious than 
any other means of treatment. One should first find out what it is that 
the child desires most — a new doll, a bicycle, etc. — and allow him to have 
it if the bed is dry, taking it away if it is wet. A reward of five cents 
for every dry night sometimes works marvels. Any measures thai pro- 
duce a marked impression upon the mind of the child sometimes have a 
beneficial effect. The inspiring of confidence that the physician will 
bring about a cure is oftentimes the mosl efficacious method of treat- 
ment. Bad-tasting drugs and mechanical measures, BUch as the passing 
of sounds, probably owe their occasional succe86 to the mental imi 
sion that they produce. 

After all local and general causes which can be discovered are 90 far 
as possible removed, there remain- i he large majority of the cases of 
enuresis in which the condition is simpl} the continuance of a had 



666 DISEASES OF THE UROGENITAL SYSTEM 

habit. To break the habit, training is of the first importance. The 
regulation of the amount of fluids is indispensable. Fluids should be 
given freely up to 4 p. m., but those who have nocturnal incontinence 
should have no fluids after that hour, a dry supper being given before 
retiring. These children are often heavy sleepers and the distention 
of the bladder does not produce a sufficient impression to waken them. 
Training should be begun during the day by voiding at regular intervals, 
and gradually lengthening the interval to accustom the bladder to dis- 
tention. At night also the child should be wakened regularly at certain 
hours to void his urine. This should be done by an alarm clock if neces- 
sary; e. g., a child who is put to bed at 7 is at first wakened at 10 p. M. 
and at 1 and 4 and 7 a. m., a record being kept of the times when the 
bed is found wet. When he goes three hours regularly at night without 
voiding, the time is lengthened to three and a half and finally to four 
hours. A child can in this way usually be trained in a few weeks to hold 
his urine with but one waking from 10 p. m. until morning; and in a 
few months this can be omitted. The number of cases which can be 
permanently cured by such simple means is most surprising. The faith- 
ful cooperation of the mother or nurse is essential to make the cure 
permanent. 

The measures described — removal of local causes, improvement of the 
general health, the institution of a proper regime and training — consti- 
tute the most important part of the treatment and in the majority of 
cases suffice, for a cure. Drugs are at times useful as accessories ; alone 
they seldom cure and, on the whole, they are disappointing. Belladonna 
is the most effective one. Atropin, either in solution or in tablet form, 
is the most convenient method of administration. For nocturnal incon- 
tinence, 1-1,000 of a grain for each year of the child's age up to seven 
years is a suitable dose. A child of five would thus be taking 1-200 of a 
grain. At first, a single dose should be given at bedtime; after a few 
days a second dose may be given three or four hours earlier; still 
later a dose may be given at 4 p. m., 7 p. m., and 10 p. M. To push the 
drug further than this may cause much discomfort and is of doubtful 
advantage. After the habit is under control, the drug should be con- 
tinued for some time and the dose reduced. 

Strychnin is sometimes advantageous when there is diurnal as well as 
nocturnal incontinence, for under these conditions there is usually a lack 
of tone in the sphincter, as wellas increased irritability in the mucous 
membrane of the bladder. Full doses are necessary; beginning with 
1-100 of a grain twice daily it may be gradually increased to 1-50 of 
a grain three times a day to a child of five. Intelligent, systematic train- 
ing is the most important of all measures for the relief of this very 
annoying condition. 



VESICAL CALCULUS 661 



VESICAL CALCULUS 



Vesical calculus is a very rare condition in children in Xew York. 
The nucleus of the calculus is usually a renal calculus which has passed 
the ureter, but has been prevented by its size from going farther. Stone 
in the bladder is extremely rare in infancy, probably owing to the fluid 
diet, but it is not infrequent in children from two to ten years of age. 
The most common variety of calculus at this time is the uric-acid. 

The symptoms in children are somewhat different from those in 
adults, and the condition is often overlooked. There is frequently pain 
upon micturition, especially at the close of the act, which may be felt 
at the end of the penis or in the perineum. There may be a sudden 
stoppage in the flow of urine. The straining often leads to rcdal tenes- 
mus and even to prolapse. This complication is so frequent that, in a 
ease of persistent prolapse, stone should always be suspected, [ncon- 
tinenee of urine is a prominent, and often Hie principal symptom; in 
many cases it is noticed only during the day. The urinary changes .ire 
not generally marked; hematuria is rare, and mucus and pus are in- 
frequent and in small quantity. The genital irritation may lead to the 
habit of masturbation. A stone of any considerable size may often be 
felt by a bimanual examination, one finger being placed in the rectum 
and the other hand above the pubes. This is easier in males than in 
females, but it is not very trustworthy, and not conclusive when it gives 
a negative result. A positive diagnosis is made only by exploring tin- 
bladder with a sound or by the X-ray. 

The treatment of calculus is purely surgical. 



SECTION VII 

DISEASES OF THE NERVOUS SYSTEM 

CHAPTER I 

The Weight of the Brain.— From ninety-eight observations made in 
the post-mortem room of the New York Enfant Asylum, the following 
were the average weights noted : 

At three months 21 oz. (602 grams). 

At six months 25J^ " (712 " ). 

At twelve months 32^ " (916 " ). 

At two years 35 " (990 " ). 

The following are the figures given by Boyd and Schafer. 



Age. 


Males. 


Females. 


Ounces. 


Grams. 


Ounces. 


Grams. 


At birth (full term) 


ny 2 
21 

27 
33 
39 

40 
46 

48^ 


330 

500 
602 

776 
941 
1,110 
1,13s 
1,301 
1,374 


10 
Hi 
20 
26 
30 
:;:» 

K) 

10' i 
44 


283 


Under three months 


150 


From three to six months 

From six to twelve months 

From one to two years 


560 

727 

si:; 


From two to four years 


990 


From four to seven years 


1 i.;.". 


From seven to fourteen years 

From fourteen to twenty years 


1 . 1 5 1 

1.211 



At birth the weight of the brain to that of the body is Dearly 1 : 8. 
During infancy and childhood the following ie the ratio, according to 
Bischoff: during the first year, 1:6; the second year, 1:11: the third 
year, i : 1 ft ; at the fourteenth year, 1 : 1"> to 1 : 25 : in adult life it is I : b'>. 

The Spinal Cord. — The weight of the cord to the weight of the body 
at birth is 1 : 500; in adult life it is 1 : 1500. According to Kolliker, the 
spinal cortl and the vertebral column arc the same length until the end of 
the third month of fetal life, there being at this time no cauda equina. 
At the ninth month the lower end of the cord ifi opposite the third lum- 
bar vertebra ; in the adult it is opposite the lir-t. 
23 869 



670 DISEASES OF THE NERVOUS SYSTEM 

Some Peculiarities in the Diseases of the Nervous System in Infancy 
and Childhood. — The relatively large size, the rapid growth, and the 
immaturity of the brain and cord during early life, explain much that is 
peculiar to the nervous diseases of this period. 

At this time, apparently trivial causes are enough to produce quite 
profound nervous impressions, because of the instability of the nervous 
centers and the greater irritability of the motor, sensory, and vasomotor 
nerves. These are conditions which are very much increased by all dis- 
turbances of nutrition. These disturbances may be manifold in character, 
but they lie at the root of very many of the neuroses of early life, e. g., 
extreme nervousness, disorders of sleep, stuttering, chorea, incontinence 
of urine, tetany, and convulsions. The great liability to convulsions 
depends not only upon the greater irritability of the peripheral nerves, 
but upon the instability of the nervous centers and the lack of inhibition 
over the motor ganglion cells of the spinal cord. The nervous centers are 
more easily exhausted than later in life. 

Another peculiarity is the serious consequences which often follow 
reflex irritation, although this is rarely the only factor in the case. Con- 
ditions which in adult life produce almost no effect may in infancy be 
the cause of most alarming symptoms. 

As a third point of importance may be mentioned the grave per- 
manent results which often follow relatively small organic lesions. A 
good illustration is seen in the lesions which produce cerebral birth-palsy. 
Here the damage is only in small part the immediate effect of the hemor- 
rhage, for this often is not great, but it is the interference with the devel- 
opment of certain parts of the cortex that makes the condition so 
serious. 

From what has been said, it follows that the hygiene of the nervous 
system is of the utmost importance in infancy and childhood. It is 
essential for the healthy development of the nervous system that all stim- 
ulants should be avoided — not only tea, coffee, and alcohol, but undue 
and unnatural excitement, the effect of which in infancy is almost as 
serious. A normal development can take place only in the midst of quiet 
and peaceful surroundings, with plenty of time for rest and sleep. The 
conditions of modern life, especially in cities, are such that these laws 
are almost invariably violated, and the consequences of this are seen 
in the marked and steady increase in nervous diseases among children 
of all classes. 



CONVULSIONS 671 

CHAPTER II 

GENERAL AND FUNCTIONAL NERVOUS DISEASES 
CONVULSIONS 

All young children, but especially infants, are extremely prone to 
convulsive disorders. In certain infants, especially those who are 
rachitic, this susceptibility is much heightened. 

Under the head of convulsions are included attacks of acute transient 
nervous disturbance, characterized by involuntary rhythmical spasm of 
the muscles, either of the face, trunk, or extremities, or all of them, 
usually accompanied by loss of consciousness. They may be regarded as 
"motor discharges" from the cortex of the brain. 

Etiologically, convulsions may be divided into those of organic and 
those of functional origin according as to whether a pathological lesion 
is or is not demonstrable. It must not be overlooked, however, that what 
we now consider functional may, with improved methods, be shown to 
depend upon an actual change in the tissue of the brain. Under the head 
of organic, or those due to direct irritation of the cortex of the brain, 
may be included all convulsions occurring with the various forms of 
cerebral disease. The most frequent are meningitis, meningeal or cere- 
bral hemorrhage, tumor, abscess, hydrocephalus, embolism, and throm- 
bosis. Developmental defects of the brain, especially microcephalus. arc 
frequently the cause of repeated convulsions that are usually classed 
under epilepsy. Convulsions due to organic disease may be found at any 
time during infancy and childhood. Because of their dependence upon 
traumatism at birth they are frequent in the first few weeks of life. 

Convulsions functional in origin are, in the overwhelming majority 
of cases, dependent upon tetany which may he either active or latent. 
It is only in the last few years that this has been sufficiently recognized. 
As will be emphasized under Tetany, the symptoms of this disease and 
the irritation of the nervous system accompanying it are not usually 
manifest before the end of the first half year, hoi- tin- reason, functional 
convulsions are much less frequent during \\\r early months of life. 

It has been held that the mosl importani predisposing cause of con- 
vulsions in infancy is the instability of the Qerve centers, vhicb is 
dependent upon a. lack of development of the voluntary centers of the 
cortex. It should be emphasized, however, that while convulsions of 
functional origin are exceedingly common in infancy, they are ao\ 
in the first three or four months of life when instabilit} of the cent 
might be assumed to be the greatest, It is quite evideui thai the instabil- 



672 DISEASES OF THE NERVOUS SYSTEM 

ity depends not upon the normal insufficiency of cerebral development, 
but upon the acquisition of tetany, which causes cerebral instability. 

It has long been held that convulsions were caused by materials 
absorbed from the gastro-intestinal tract. It is certainly true that over- 
feeding or indigestion may excite convulsions. This is usually, however, 
in children suffering from tetany and it is very likely that the convul- 
sions are not due to any specificity of the material absorbed, but that 
any irritation to the child's nervous system is likely to be followed by 
convulsions. Convulsions are sometimes seen, it must be admitted, in 
infants when no evidence of organic disease can be detected, nor any 
symptoms of tetany and no hyperexcitability of the nervous system as 
shown by electrical examination. The cause of these is not clear. 

Convulsions are apparently at times of toxic origin. They may result 
from conditions like uremia and asphyxia and also at the onset or in 
the course of various infectious diseases. They are more frequent in 
children who have or have had tetany, but may be found without any 
evidences of this. They are very frequent at the onset of certain diseases, 
particularly pneumonia, scarlet fever, malaria and acute indigestion. 
In pertussis, which, of all the infectious diseases, is the one in which 
convulsions are most frequent, several factors may be present: asphyxia, 
due to a severe paroxysm, cerebral congestion or hemorrhage resulting 
from such a paroxysm, or simply a peculiar susceptibility of the patient 
brought about by the disease itself. One attack of convulsions, whatever 
the cause, renders the patient more liable to a second attack and when 
there have been several, they occur from causes which are less and less 
marked. 

An infrequent cause of convulsions in young children is an encephal- 
opathy due to lead poisoning. We have seen, four such cases, three of 
which were fatal. The poisoning was caused in each instance by the 
child's nibbling and swallowing the paint from his crib or furniture. 

Convulsions ending fatally are not infrequently associated with en- 
largement of the thymus gland. We have seen many such where there 
was found at autopsy great enlargement of the thymus, and the lymphatic 
structures. Some of these infants were previously healthy; some were 
rachitic. The similarity of all these cases indicated that the convulsions 
were in some way associated with the enlarged thymus, but the exact 
explanation of such cases is not understood. In infants who die during 
convulsions the brain may be the seat of punctate hemorrhages, and some- 
times of more extensive ones. The lungs are also deeply congested, and 
the right heart is generally distended with dark clots. The other lesions 
found are accidental. 

Symptoms. — In some cases prodromal symptoms are present, such as 
extreme restlessness, irritability, slight twitchings of the muscles of the 



CONVULSIONS 873 

face, hands, feet, or eyelids. More frequently, however, the attack conies 
quite suddenly with little warning. Usually the first thing noticed is 
that the face is pale, the eyes fixed, sometimes rolled up in their orbits; in 
a moment or two, convulsive twitchings begin in the muscles of the 
eye or face, or in one of the extremities, which usual I v rapidly extend 
until all parts of the body participate. Tn most cases the convulsions 
become general, but they may remain unilateral even when not due to 
a local cause — a point which is often forgotten. The contraction of 
the facial muscles causes a succession of grimaces; the neck is thrown 
back; the hands are clenched; the thumbs buried in the palms; and a 
quick spasmodic contraction of the extremities occurs. There may be 
some frothing at the mouth, and in all true convulsions there is loss of 
consciousness. Eespiration is feeble, shallow, and may be spasmodic 
The pulse is weak; it may be slow or rapid; often it is irregular. The* 
forehead is covered with cold perspiration. The face is first pale, then 
becomes slightly blue, especially about the lips. Unnatural rattling 
sounds may be produced in the larynx. The bladder and rectum may be 
evacuated. The convulsive movements consist in an alternation of flexion 
and extension occurring rhythmically. All varieties of tonic and clonic 
spasm may be seen, and in all degrees of severity. The contractions of 
the two sides of the body are usually synchronous. After a variable time, 
from a few moments to half an hour, the convulsive movements grad- 
ually become less frequent, and finally cease altogether, usually leaving 
the patient in a condition of stupor. They may recur after a short time 
or there may be but one attack. A period of general relaxation usually 
follows the convulsive seizures, frequently accompanied by marked evi- 
dences of prostration. Transient paralysis, apparently due to exhaus- 
tion of the nerve centers, is not an uncommon sequel. 

Death may take place from a single attack; this, however, is rare ex- 
cept in very young infants, or those with status lymphaticus. There may 
be no sequel to the convulsions if the cause is a temporary one. or they 
may produce some serious brain lesion, particularly meningeal hemor- 
rhage. Death from convulsions is generally due to asphyxia, or to ex- 
haustion from the rapidly recurring attacks. Many cases recover in 
which the children for several minutes had the appearance of being 
moribund. 

One attack of convulsions is very apt to he followed by others, espe- 
cially if tetany be the cause. The longer the interval whieh has passed, 
the less likely is there to be a repetition, especially if the child has passed 
his third year. 

Biagnosis. — There can rarely he any difficulty in recognizing an 
attack of convulsions. The difficulty consists in determining with which 
of the many possible exciting causes we haw to deal in the case before 



674 DISEASES OF THE NERVOUS SYSTEM 

us. If it comes with acute symptoms does it depend upon a cerebral 
lesion, or does it mark the onset of some other acute disease? Is it due 
to tetany? If there are no acute symptoms, is it epilepsy? To answer 
these questions a careful history must be obtained, and all the circum- 
stances surrounding the patient, the character of the convulsions, and 
all the other symptoms present must be taken into consideration. Tetany 
is easy to recognize if there is carpopedal spasm, Chvostek's sign, laryn- 
gospasm, or Trousseau's sign. If these are absent, it can only be deter- 
mined by the electrical reactions. Tetany is to be considered the most 
likely cause, however, in the absence of the evidence of organic cerebral 
disease. 

In infancy, epilepsy is the least probable diagnosis. In older children 
the important points indicating that disease are : a history of previous 
attacks, a distinct aura preceding the seizure, or a sudden onset with a 
cry or fall, biting of the tongue, a deep sleep following the seizure, and, 
finally, perfect recovery in the course of a few minutes or hours. Convul- 
sions which come on with high fever, even though a patient may have 
repeated attacks, are seldom epileptic. However, in some cases only 
prolonged observation can enable one to decide positively whether or 
not epilepsy is present. 

Convulsions occurring in brain disease, except acute meningitis, are 
not as a rule accompanied by any marked rise in temperature. Focal 
symptoms are often present, such as localized paralysis or rigidity, 
changes in the pupils, and strabismus. The convulsive movements are 
frequently limited to one side of the body. It should, however, be borne 
in mind that unilateral convulsions, even when repeated, do not always 
mean a local lesion, as we have seen proved by autopsy more than once. 
In hemorrhage or meningitis, convulsions are likely soon to recur. In 
tumor they may recur after a longer interval. 

Convulsions may be thought to indicate the onset of some acute dis- 
ease when they occur in a child over two years old, and when they come 
on suddenly or with only slight premonition in a child previously well; 
but the most important point is that they are accompanied by a high 
temperature — 104° to 106° F. Acute meningitis is the only other con- 
dition likely to produce these symptoms. Whether the convulsions mark 
the onset of lobar pneumonia, scarlet fever, or some other disease, can 
be determined only by carefully watching the patient's symptoms for 
twenty-four or thirty-six hours or possibly longer. 

In the first weeks of life one may often be in great doubt as to the 
cause of convulsions. Such attacks may be due to some disorder of the 
digestive tract, to a recent cerebral lesion like hemorrhage, or to a defec- 
tive brain development. Apparently prolonged pressure in a difficult 
labor may produce 1 temporary, perhaps circulatory, changes in the brain 



CONVULSIONS 67.3 

sufficient to cause convulsions during the first few days of life. We have 
seen them in a number of children whom we have had an opportunity 
to follow for several years. Their physical and mental development has 
progressed in a perfectly normal manner. 

Examination of the urine should not be omitted in any case of con- 
vulsions of doubtful origin. Asphyxia may be suspected in the case of 
convulsions occurring in the newly born, late in pneumonia, in some cases 
of pertussis, in spasmodic or membranous laryngitis, or with larvngo- 
spasm. It is altogether improbable that dentition and worms play any 
part in the causation of convulsions except perhaps that of the slight 
irritant which is sufficient to excite convulsions in a child suffering from 
tetany. 

Encephalopathy due to lead should be kept in mind as a rare cause 
of convulsions in children. The blue punctate line in the gums can 
usually be found, though not around each tooth. There is also stippling 
of the red blood-cells. The cerebrospinal fluid is under increased pres- 
sure, the cells are slightly increased in number and there is a positive 
reaction for globulin. There is frequently pallor of the optic discs and 
hemorrhages into the retina may be seen. 

In all cases of convulsions occurring in infants in which the can-' is 
not readily apparent, tetany should be suspected as the underlying con- 
dition. 

Prognosis. — This depends upon the cause of the convulsions, and 
differs with each underlying cause. In general it may be said that con- 
vulsions in themselves are seldom fatal unless they occur as a terminal 
condition. Especially fatal are the convulsions of pertussis and of 
asphyxia when they occur late in any form of laryngeal or pulmonary 
disease. The conditions during an attack which should lead one to make 
a bad prognosis are when the convulsions are prolonged or recur fre- 
quently; also the presence of very great prostration, a feeble pulse with 
cyanosis, or deep stupor. 

In the prognosis one must take into account not only I he immediate 
result of the attacks, but the possible outcome. In a highly nervous or 
susceptible child a convulsion often mean- very little. Permanent injury 
to the brain, simply as a result of an attack, is very rare. The possibility 
of epilepsy is to be borne in mind in all cases where children over fcwo 
years old have occasional attacks of convulsions. The farther apart the 
attacks are and the more definite the exciting cause, the less likely ifl 
this to be the case. 

Treatment. — Summoned to a child in convulsions, a physician Bhould 
go at once and remain until the attack has subsided, lie should take 
with him chloroform, a hypodermic Byringe with morphin, a sofl cath- 
eter or rectal tube, and a solution of chloral. In order t<» treat eonvul- 



676 DISEASES OF THE NERVOUS SYSTEM 

sious intelligently one must have in mind the prominent pathological 
conditions. These are acute cerebral hyperemia, a more or less severe 
asphyxia with pulmonary congestion, an overtaxed right heart, and a 
tendency to congestion of all the internal organs. The nervous centers 
are in a condition of such unnatural excitability that the slightest irrita- 
tion may bring on convulsive movements when they have temporarily 
subsided. The patient should therefore be kept perfectly quiet, and every 
unnecessary disturbance avoided. Cold should be applied to the head — 
best by means of an ice cap or cold cloths — and dry heat and counter- 
irritation to the surface of the body and extremities. The time-honored 
mustard bath causes so much disturbance of the patient that it can usually 
be dispensed with and the mustard pack substituted. The feet may be 
placed in mustard water while the child lies in his crib. The mustard 
pack and footbath should be continued until the skin is well reddened. 
The degree to which counter-irritation of the skin should be carried 
will depend upon the condition of the pulse and the cyanosis. 

In controlling convulsions the remedies which may be depended upon 
are the inhalation of chloroform, chloral per rectum, morphin and mag- 
nesium sulphate hypodermically. Chloroform is undoubtedly the most 
reliable remedy for an immediate effect, and may be used even in the 
youngest infant. At the same time that it is being administered, chloral 
may be given. The initial dose should be, at six months, four grains; 
at one year, six grains; at two years, eight grains, dissolved in one 
ounce of warm milk. It should be injected high into the bowel through 
a catheter, and prevented from escaping by pressing the buttocks to- 
gether. It may be repeated in an hour if necessary. The effect of the 
drug is generally obtained in twenty or thirty minutes. If, in spite of 
the chloral, the convulsions show a marked tendency to continue as soon 
as the chloroform is withdrawn, or if the enema of chloral has been 
expelled, morphin may be given hypodermically. When the heart's ac- 
tion is weak, this is probably the best of all remedies. To a well-grown 
child two years old, T ^ grain may be given ; one year old, ■£$ grain ; six 
months old, -j^ grain. This dose may be repeated in half an hour if no 
effect is seen. The tolerance of opium in cases of convulsions is very 
marked, and sometimes double the doses mentioned may be required. 
For frequently recurring convulsions magnesium sulphate, hypodermic- 
ally, is a valuable remedy. It has the advantage over morphin in that it 
does not constipate. Eight or ten grains of Epsom salts may be given to 
an average infant of three or four months, and from fifteen to twenty 
grains to one of six or eight months. It does not act so promptly as does 
morphin. The dose may be repeated in two hours if necessary. The 
only other agent of much value is oxygen. We have occasionally seen 
convulsions which continued in spite of all other treatment yield imme- 



TETANY G77 

diately to oxygen. This is most likely to be valuable in cases of convul- 
sions due to asphyxia. 

In infancy it is wise in every case to irrigate the colon thoroughly 
with warm water, to remove any possible source of. irritation. If there 
is reason to suspect the presence of undigested food in the stomach, this 
may be washed out. Much more frequently it is in the intestines, and 
free purgation by calomel is advisable. If there is high temperature, 
this should be reduced by the cold bath or pack. 

When once under control, the recurrence of the convulsions may be 
prevented by keeping the patient for two or three days under the influence 
of chloral with bromid of sodium, the amount of chloral being gradually 
reduced. If it is badly borne by the stomach and not easily retained by 
the rectum, either antipyrin or phenacetin may be used with the bromid. 
As soon as the convulsions have ceased, the cause should be sought and 
treated. 

TETANY 

Several clinical conditions, formerly described under different 
names, are now regarded as manifestations of tetany : arthrogryposis or 
carpopedal spasm, laryngismus stridulus or iaryngospasm, holding-breath 
spells, etc. 

Tetany is a disease characterized by an extreme irritability of the 
nervous system to mechanical and electrical stimulation. It is frequently 
accompanied by more or less prolonged contractions of the muscles of the 
extremities. Spasm of the glottis and also general convulsions are very 
common. It was formerly believed that tetany was rather infrequent 
and was manifested only by muscular spasm. Studies by electrical 
methods, however, have shown that in infancy and childhood the disease 
is exceedingly frequent and that it may exist without giving any symp- 
toms, i. e., in a latent form. To the latent form of the disease as well 
as to all the manifestations, the term "spasmophilia " or "spasmophilic 
diathesis/* has been applied by many. 

Etiology. — While tetany is found with the greatest frequency during 
the latter half of the first and during the second year, it is very rarely 
seen in the first three months of life. Jt may occur at any time during 
childhood but its frequency diminishes rapidly with age. Tetany is 
rare in summer and early auiumn, hut it is very common in winter and 
early spring. The association of tetany with rickets is a very close one. 
Not only is it found at the time of year when active rickets is most com- 
mon, but almost all children with tetany show some of the symptoms 
of rickets. While cases are observed in which no rachitic manifestations 
are present, rickets cannot he entirely excluded, for, as has been stated 



078 DISEASES OF THE NERVOUS SYSTEM 

elsewhere, the first evidences of rickets in the bones escape clinical ob- 
servation. Symptoms of both rickets and tetany begin to be seen at 
about the same age. While tetany may occur in the breast-fed, this is 
relatively infrequent. The disease evidently depends for its development 
largely upon artificial feeding but occurs even when this has been appar- 
ently proper. 

Tetany seems to be closely connected with changes in the calcium me- 
tabolism, although these are not yet entirely clear. It has been shown 
in a certain number of patients that with active tetany, just as with 
active rickets, there is a negative calcium balance — more calcium being 
eliminated than is ingested with the food. There has also been found 
post mortem a deficiency in the calcium content of the brain. Mariott 
and Howland have demonstrated a marked reduction of the calcium of 
the blood of infants with active tetany. MacCallum and Voigtlin have 
shown a deficiency of calcium in the blood of animals with experimental 
tetany. It is therefore clear that there is some alteration of calcium 
metabolism in tetany. 

The removal of the parathyroids in animals and the occasional acci- 
dental injury of these in human surgery produces a condition closely 
akin to tetany. The work of Erdheim, Escherich and Yanase indicated 
that the parathyroids might be diseased in tetany, the changes consisting 
in hemorrhages and their remains. Later observations have shown that 
these alterations may be found in children who, during life, have given 
no evidence of tetany and also that the glands may be normal when defi- 
nite tetany has been present. It is as yet impossible to say whether the 
parathyroids play an important part in the disease. There is, however, 
sufficient evidence to indicate that they may have some influence upon its 
production. Tetany is at times hereditary. There may be a history of 
the disease in one of the parents and occasionally families are found 
with several children who have suffered from tetany. Acute disease, 
especially when accompanied by fever, is sometimes the exciting cause. It 
must be assumed that up to the onset of the acute disease tetany has 
been latent, the new condition providing the necessary irritation to make 
the tetany active. Thus, tetany is seen with acute diseases of the gastro- 
intestinal tract, pneumonia and the acute infectious diseases. 

There are no characteristic pathological changes other than those of 
the associated rickets. In a certain proportion of the cases alterations in 
the parathyroids are found. One or more of the four glands may be 
enlarged and red as a result of extravasation, or the changes may only 
be evident under the microscope and consist in small hemorrhages, and 
the remains of hemorrhages. 

Symptoms. — One of the most characteristic and striking is carpo- 
pedal spasm. It is, however, by no means the most common manifesta- 



TETANY 



679 



tion, and is seen in only a small percentage of the eases. The spasm 
of the hands and feet may develop abruptly, or it may be preceded by 
sensory disturbances. The upper extremities are usually first affected and 
both sides equally. The position is very characteristic : The fingers are 




Fig. 86. — Tetany, showing the Characteristic Position of the Hands and Feet. 

In a child two years old. 



flexed ai the metacarpophalangeal joints and the phalanges extended; the 
thumbs are adducted almosl to the little finger; the wrisi is flexed acutely 
and the hand drawn somewhal to the ulnar side. It' the spasm is very 
marked do motion is allowed al the wrist. The fed arc strongly ex- 
tended, sometimes in the position of equinovarus. The firsl phalanges 



680 DISEASES OF THE NERVOUS SYSTEM 

of the toes are flexed, and the second and third rows extended ; the plantar 
surface is strongly arched and the dorsum of the foot is very prominent, 
standing out like a cushion. The typical position of the hands and feet 
is well shown in Fig. 86. Motion at the elbow, shoulder, hip and knee 
is generally free. The spasm in many cases is limited to the hands and 
feet; more rarely the muscles of the thigh, usually the adductors, may 
be involved. In rare cases the muscles of the trunk or the face may be 
affected. The spasm can be voluntarily overcome to a certain extent; 
thus a child may open his hands to grasp objects or feed himself. As 
soon as active motion ceases, the hands resume their former characteristic 
attitude. 

Evidences of pain are frequent ; it may be so severe as to cause chil- 
dren to cry out. Pain may J^e induced by any attempt to overcome the 
spasm, and sometimes it is constant. There is no loss of consciousness 
and no fever. The duration of carpopedal spasm may be from a few 
hours to several days. The muscular contraction is generally continuous, 
although there are often periods of remission. There may be only a single 
short attack. Of this we have seen several striking instances. One child 
seven years old who had always been well was operated upon for enlarged 
tonsils. The night following operation she cried out with pain and her 
hands and feet were found in the typical position of tetany. In four or 
five hours this completely disappeared and did not return. This was the 
only symptom of tetany that she ever manifested. Carpopedal spasm 
may come on spontaneously but is more frequently found in the course 
of some febrile illness. It is found in no other disease and is diagnostic 
of tetany. 

Disturbances of respiration are exceedingly common in tetany. The 
most typical of these is spasm of the glottis or laryngospasm. This con- 
sists in a contraction of the laryngeal muscles of such intensity as par- 
tially to obstruct inspiration or for a time to arrest it. When the obstruc- 
tion is partial there is a very characteristic crowing sound with each 
inspiration, especially if the child is disturbed or crying. There may be 
a succession of these sounds, followed by an intermission, or the condition * 
may last in a mild form for several minutes or hours. The severe attacks -* 
of obstructed respiration usually come on suddenly. The child throws* 
back his head, the face becomes pale, then livid, and for the time there 
is complete arrest of respiration. This continues for a few moments, 
during which the cyanosis deepens, and the child seems in great distress, 
making violent efforts to breathe. If the paroxysm is very severe, the 
asphyxia may be so great as to lead to loss of consciousness, or the attack 
may terminate in general convulsions. It may even be fatal. In less 
severe attacks, after fifteen or twenty seconds the muscular spasm relaxes, 
the glottis opens, and a long, deep inspiration occurs, with the production 



TETANY 081 

of a crowing sound. Such forms of spasm often come on without evident 
cause, and may be repeated from two to twenty times a day. Between 
them the condition of the child may be normal or carpopedal spasm and 
other evidences of tetany may be present. Xot all the paroxysms are 
equally severe. A child may have in the course of a day a great many 
mild attacks, but only a few severe ones. Cieneral convulsions are seen _ 
in over one-third of the severe cases. Laryngospasm is most common 
in children from six to fifteen months of age. iy _ >*\ *y^ 

Attacks closely related to those which have just been described are 
met with in which respiration entirely ceases for a time; there are tem- 
porarily no attempts at inspiration. It has been assumed that the dia- 
phragm participates in the spasm. Attacks with temporary arrest of 
respiration are seen most frequently in the latter part of the first and 
during the second year, but beginning in infancy they may recur from 
time to time until the age of four or five years. They affect children of 
an extremely nervous type. Several attacks may occur in a single day. 
or they may occur at intervals of several days or weeks. In susceptible 
children almost any form of excitement may precipitate one. They are 
often known as ^oi^gd&ejLili^spells." In older children by far the 
most frequent exciting causes are temper and fright. If anything is 
attempted to which the child strongly objects, e. g., a cold bath, inspection 
of the throat, or taking away a toy, an attack may ensue. The child's 
face becomes flushed, then livid; there is general rigidity of the trunk 
and extremities, but very rarely clonic spasms. This rigidity is usually 
followed by complete relaxation with loss of consciousness. The entire 
attack usually lasts about half a minute. There may be a crowing sound 
as the child catches his breath or there may be none. After a few minutes 
of quiet the child gets up and in a short time is apparently as well as 
ever. Many of those who are subject to attacks of this sort sooner or 
later have one or more general convulsions, but in some only the mild 
attacks are seen though they may recur at intervals for years. Death 
occasionally occurs with severe attacks, there being no renewal of respira- 
tion and all attempts at resuscitation failing. 

Lederer has described a complex of pulmonary symptoms closely 
simulating asthma. This he has termed broncho-tetanie. It is not 
clear that the symptoms which he describes a, re necessarily dependent 
upon tetany. 

General convulsions are exceedingly common with tetany in infancy. 
After that they are less frequently seen. They differ in no respect from 
those that have been described in the previous chapter. The more fre- 
quent the convulsions, the milder they usually arc. From the character 
of the convulsions alone, it is Impossible to differentiate them from 
epilepsy. They may occur without any exciting cause or the leasl stiniu- 



682 DISEASES OF THE NERVOUS SYSTEM 

lus may be sufficient to cause an attack. Thus we have seen a child who 
repeatedly had convulsions whenever cold was applied to the skin. The 
number of attacks may be very great. In one case that we saw, an 
infant during the latter part of his second year had, during six months, 
over 3,500 distinct' attacks of convulsions. For a considerable period they 
reached the almost incredible number of 80 a day. After improvement 
occurs, the number may gradually diminish or more frequently they may 
cease almost at once. Death is infrequent during a convulsion but occa- 
sionally occurs, apparently from exhaustion, when severe convulsions are 
frequently or uninterruptedly repeated. 

When tetany is suspected, three confirmatory signs should be sought : 
Chvostek's sign or the facial phenomenon, Trousseau's sign, and Erb's 
sign. Chvostek's sign consists in a momentary contraction of the muscles 
of the face when a branch of the facial nerve is tapped with the per- 
cussion hammer or with the finger. The nerve may be tapped anywhere, 
but usually best about the middle of the check. The contraction may 
affect only the mouth and the alae nasi, or it may involve any of the 
muscles supplied by the nerve. This sign is not found in the first two 
years of life, except in cases of tetany. t Later, it is of more frequent 
occurrence and less reliance can be placed upon it as an evidence of tet- 
any, particularly after the fifth year. Thiemich, however, maintains that 
it always indicates tetany. But it is found in such a large proportion of 
older children in whom no symptoms or history of tetany can be obtained 
that it is generally believed to indicate in them only a neurotic con- 
stitution. 

Trousseaus sign is elicited by pressure by the hand or a bandage 
upon the blood vessels of an extremity with sufficient force to stop the 
circulation temporarily. The sign is most easily elicited in the upper 
extremity when pressure is made above the elbow. The radial pulse 
should be obliterated for several minutes. Then the hand may assume 
the typical position of carpopedal spasm. The sign is often absent in 
well-marked tetany, but when present is to be regarded as positive evi- 
dence of tetany. 

Erb's sign or lite quantitative reaction of the nerves to the galvanic 
current. 1 — Muscular contractions are produced by the application of the 

1 For the electrical determinations a galvanic battery with a milliamperemeter 
graduated in fifths up to five milliamperes is necessary. The measurements are 
usually made upon the peroneal nerve. The large indifferent electrode should be 
placed upon the abdomen, the stimulating electrode upon the peroneal nerve in 
the outer part of the popliteal space near the head of the fibula. 

The cathodal closure contraction is often obtained with a current less than 5 
milliamperes in strength in normal children under six months of age, and after 
this time it is regularly present with a current of this strength or a weaker one. 
No evidence in regard to tetany may be obtained from the C.C.C. The anodal 



TETANY 683 

galvanic current to the nerves. These contractions occur with the making 
or breaking of the current and are called "closing" and "opening" con- 
tractions, respectively. The nerves react differently to the different poles 
and also to the making or breaking of the current. Age also has an 
important influence in the character of the electrical response. The 
nerves of the newly born and of infants during the first year are less 
responsive to the current than those of children who are older. The 
excitability increases with age up to about five years, after which there 
is little if any difference between the child and the adult. Closing 
contractions occur in early childhood with a weaker current than do 
opening contractions. 

In the first six months of life any contraction with a current of less 
than 5 milliamperes, except that of cathodal closure, points to tetany ;i 
while an opening contraction, either cathodal or anodal, with a current 
weaker than 5 m. ap. is positive evidence of tetany. 

Under two years of age an A.O.C. with a current of less than 5 
m. ap. and weaker than one which will cause an A.C.C., is presumptive 
but not positive evidence of tetany. C.O.C. or C.C. tetanus with a 
current of less than 5 m. ap. in a child under five may be considered 
hvperexcitability due to tetany. Repeated measurements upon the same 
child often give different results in the course of a few days. For this 
reason several electrical examinations are frequently necessary to deter- 
mine or exclude tetany. 

closure usually requires more than 5 m. ap. of current with infants less than six 
months of age. From that time up to two years the A.C.C. is frequently, and 
after two years regularly, obtained with a current less than 5 m. ap. strength. 
An A.C.C, therefore, with a current of less than 5 m. ap. is suggestive of tetany 
only in the first six months. 

The anodal opening contraction in the first six months of life occurs with 
normal children only with a current of more than 5 m. ap. strength and up to 
two years it almost always requires a current of more than this. It also usually 
requires more current to produce an A.O.C. than an A.C.C. until the second or 
third year. After five years of age the A.O.C. is regularly obtained with a cur- 
rent of less than 5 in. ap., and less than is required to produce an A.C.C. 
An A.O.C. therefore in the first six months of age obtained with a current less 
than 5 m. ap. is strong evidence of tetany and under two years of age is sug- 
gestive of tetany, especially if the A.O.C. takes place with a current less than 
is required to produce an A.C.C. This was called by von Pirquet "anodal hyper- 
excitability." We cannot regard it as more than highly suggestive of tetany after 
six months of age, for it sometimes occurs with children that are apparently 
entirely normal. After two years of age it is often present and after five years 
of age regularly so with normal children. 

A cathodal opening contraction or cathodal cloning tetanus, occurring with a 
current of less than 5 m.ap. in children under fixe years of age, is positive evi- 
dence of tetany. After that time such values may occasionally be found with 
quite normal children. 



684 DISEASES OF THE NERVOUS SYSTEM 

The conception of "latent" tetany was gradually reached when it was 
appreciated that muscular spasm of the extremities, laryngospasm and 
general convulsions were all symptoms of the same basal disorder. The 
electrical reactions also were shown to be in many instances the same in 
children that had suffered from no spasmodic symptoms, as in those 
who were the subjects of frank tetany. If the former were followed 
carefully it was often noticed that, sooner or later, convulsions, laryngo- 
spasm or carpopedal spasm developed. It is therefore apparent that there 
is an instability of the nervous system that, without electrical measure- 
ments, may exist unsuspected until suddenly it becomes clinically evi- 
dent. Electrical measurements upon a large number of children in 
hospital and out-patient practice have shown that latent tetany is a fre- 
quent condition and that undoubtedly only a small percentage of these 
children show symptoms by which the disease is recognizable. 

Various other symptoms have been ascribed by writers to tetany. 
Thus, Ibrahim has emphasized spasm of the pylorus producing vomiting, 
of the intestines, causing pain and meteorism, and of the anal sphincter 
leading to obstinate constipation. The occasional retention of urine in 
tetany has been referred to spasm of the vesical sphincter. The fatal 
outcome in some cases of general convulsions or those with laryngospasm 
it is claimed results from tetany of the cardiac musculature. The relation 
of all of these conditions to tetany is very doubtful. 

From what has been stated it is evident that the variations in the 
course of the disease may be extreme. Tetany may entirely escape 
observation or it may give symptoms for months or even years. There 
is a surprisingly close connection between the condition of the bowels 
and the symptoms of tetany. In most patients tetany is aggravated by 
the existence of constipation. A sharp attack of diarrhea or free purga- 
tion by medicine regularly causes a diminution and often a complete 
disappearance of all symptoms including the abnormal electrical irritabil- 
ity. As the result of dietetic treatment, a marked diminution in the 
intensity and frequency of the attacks may be observed. They often 
cease altogether in a short time. Other cases are observed, however, in 
which improvement is very slow. In those children that suffer from 
malnutrition a proper growth and gain in weight may be difficult to 
obtain. 

Diagnosis. — This may be easy or so difficult as to be possible only 
after prolonged observation. Carpopedal spasm, laryngospasm, Trous- 
seau's sign and Chvostek's sign under five years, are pathognomonic symp- 
toms. But in perhaps the largest number of children with tetany none 
of them is present. The electrical reactions are usually conclusive, but 
at times may be of little assistance. If an infant with no evidences of 
an organic brain lesion has repeated attacks of convulsions tetany should 



TETANY 685 

always be suspected. If there are symptoms of rickets and if the attacks 
are frequent the probabilities of tetany are greatly increased. The chief 
difficulties in diagnosis are with older children who suffer from occasional 
convulsions. It may be almost impossible without prolonged observation 
to decide between epilepsy and tetany. Electrical reactions at this age 
offer little assistance. The older the child the greater are the chances 
in favor of epilepsy. 

Prognosis. — The prognosis of tetany varies greatly with the age of 
the patient, the type of the disease and its severity. The prognosis of 
latent tetany is always good, with proper treatment. In general, the 
younger the patient the more severe the manifestations of tetany are 
likely to be and the more difficult to control. After two years, except in 
markedly rachitic children, the prognosis as to life is always good. The 
chances are always in favor of recovery when there are only occasional 
attacks of general convulsions. With frequently repeated convulsions 
there is danger to life, not only from the convulsions themselves, but 
from the frequent association of severe attacks of laryngospasm. This 
must always be looked upon as a dangerous manifestation of tetany and 
infants may die during such attacks. 

Tetany complicating gastro-intestinal or any acute infectious disease 
makes its prognosis less favorable. According to Thiemich and Birk, the 
mental development of children who have suffered from severe tetany is 
often greatly retarded and, in many cases, permanently interfered with. 
The physical development also suffers. More observations are required 
definitely to settle this point. It is apparent, however, that tetany may 
leave permanent effects. 

Treatment. — Prophylaxis should be emphasized. Tetany does not 
often occur with breast feeding. Maternal nursing is not only the best 
preventive, but feeding with woman's milk is also the best means of 
stopping the further progress of tetany when it has once developed. It 
does not, however, rapidly cure the disease. With infants under eight 
months of age who give symptoms of tetany woman's milk should be 
supplied if possible. Treatment should be directed not only against the 
manifestations of tetany but also against the fundamental metabolic dis- 
turbance upon which they depend. The treatment of this basal con- 
dition is the treatment of the associated rickets. It differs in no respect 
even though we recognize that the two conditions are not similar. Hi is 
has been discussed in the Chapter on Rickets. The only exception to 
this general statement is that during the presence of attacks of convul- 
sions and laryngospasm or carpopedal spasm it may he advisable to 
remove all cow's milk temporarily from the food. While it is true that 
overfeeding with cow's milk apparently causes and certainly aggravates 
tetany, in the event that breast feeding is impossible, cow's milk cannot 



686 DISEASES OF THE NERVOUS SYSTEM 

be altogether removed from the diet, except for a short period. There 
is no advantage in excluding it for a long period. The most satisfactory 
results are generally obtained when feeding is carried on according to 
the indications afforded by the child's digestive symptoms. There is a 
distinct advantage in providing a mixed diet with a minimum amount 
of milk as soon as the child's digestion will allow it. 

The specific treatment of tetany by parathyroid extract has not been 
followed by any appreciable benefit, nor has the administration of calcinm 
in onr hands given favorable results. There can be no doubt that the 
prolonged administration of cod-liver oil and phosphorus is beneficial 
in a certain number of cases. They are to be used as in rickets. 

General convulsions are to be treated according to the methods given 
in the previous chapter. Chloroform, chloral, morphin and magnesium 
sulphate are all useful and are to be employed for rather different indica- 
tions. In an average case in an infant the last mentioned remedy is to 
be preferred. It is given subcutaneously in doses mentioned under Con- 
vulsions. If the convulsions are frequent it is advisable to withdraw 
cow's milk from the diet entirely for a time. Gruels may take its place 
for several days. When milk is again included in the diet it should be 
added very gradually and in minimum amount. 

Laryngospasm, if severe, requires the administration of calcium bro- 
mid by mouth or chloral by rectum until the frequency and severity of 
the attacks are controlled. Antipyrin at times seem to be more effective 
than bromid or chloral. If during attacks there are no efforts at inspira- 
tion, artificial respiration should be performed and possibly intubation 
may be of value. The dietetic treatment should also be the same as when 
general convulsions are severe. Carpopedal spasm is often relieved by 
prolonged warm baths or by the application of warm compresses. Bro- 
mids, chloral or antipyrin are also to a certain extent useful in relaxing 
the spasm. Latent tetany requires no treatment other than the general 
dietetic and hygienic treatment directed toward the correction of the 
basal disturbance of metabolism. 

EPILEPSY 

Epilepsy cannot be considered a sharply limited disease. Eather it 
is to be looked upon as consisting of certain symptom-complexes that 
are frequently repeated and arise as the result of widely different causes, 
some known and some unknown. Moreover, these symptom-complexes 
are to a certain extent interchangeable. Epilepsy is manifested by re- 
peated general or localized muscular spasm with or without loss of con- 
sciousness and by peculiar mental states, the so-called "equivalents." 

A distinction must be made between cases of so-called "idiopathic" 



EPILEPSY 687 

epilepsy, or those without gross anatomical basis, and those which are 
secondary to a definite lesion of the brain, such as tumor, sclerosis or 
abscess. Convulsions of the latter character are designated as "symp- 
tomatic" epilepsy, and are discussed in connection with the various 
diseases in which they occur. The nature of the attack may, however, 
be identical in both varieties, and may not differ from an ordinary attack 
of convulsions or eclampsia. The proportion of idiopathic cases in chil- 
dren is not so large as was formerly siipposed; many of these have been 
shown to depend upon lesions once overlooked, particularly mild infantile 
cerebral paralyses. 

Etiology. — From a consideration of 1,450 cases of epilepsy, Gowers 
states that 12 per cent begin in the first three years of life, and 46 per 
cent between ten and twenty years. The greatest tendency to the develop- 
ment of the disease is shown about the time of puberty. Females are 
rather more liable to be affected than males, although the difference in 
sex is slight. Heredity plays the most important role in the production 
of the disease. It is estimated by \arious authors that from 35 to 65 
per cent of epileptics come from epileptic families. Echevierra investi- 
gated the families of 135 epileptics and found that of their 533 children, 
78 were epileptic and that 126 manifested various forms of nervous and 
mental diseases. The influence of alcoholism in the parents upon the 
production of epilepsy cannot be estimated with certainty. It is hardly 
to be doubted that it is a factor of importance in at least a certain per- 
centage of cases. Syphilis also must be looked upon as the cause of 
some of the cases. Whether, in the absence of definite anatomical lesions, 
it so affects the brain as to lead to epileptic seizures cannot be stated at 
the present time. Further studies with the assistance of the Wassermann 
reaction are necessary to decide this question. 

It was formerly believed that infantile convulsions were not infre- 
quently followed by epilepsy in later years. There are numerous causes 
for convulsions in infancy. By far the greatest number not due to or- 
ganic brain disease depend upon tetany. Not sufficient time has elapsed 
nor sufficient observations been made since the more recent knowl- 
edge of tetany to say whether it is likely to induce epilepsy. There is 
no good reason, however, to suppose that it docs. Convulsions in infancy 
that are followed by epilepsy are probably epileptic from the beginning. 

An innumerable number of other causes have been suggested, such as 
autointoxication from the intestinal tract, worms, adenoid vegetations of 
the pharynx, phimosis, masturbation, etc. That poisons absorbed from 
the intestinal tract can cause convulsions is probably true, bul thai epi- 
lepsy results in this way is very much to be doubted. The influence of 
the other factors suggested awaits any definite proof. 

Pathology. — If one includes in the pathology of epilepsy Hie symp- 



088 DISEASES OF THE NERVOUS SYSTEM 

tomatic cases the changes in the brain are striking and of the greatest 
variety. These, however, do not concern us here. There has been much 
written and many careful observations made upon the changes in the 
so-called idiopathic cases. While it is perhaps true that, with improved 
technic and new methods, more definite and conclusive alterations in the 
brain will be found, it must be admitted that at the present time in the 
opinion of very competent authorities certain alterations can be demon- 
strated in the majority of instances. These are chiefly lesions in the 
cortex that can only be observed microscopically. A generalized gliosis 
has been described by Bleuler, Alzheimer and Chaslin. Meynert has 
observed a sclerosis in the cornu ammonis and Bedlich and others have 
demonstrated various degenerative changes in the ganglion cells as well. 

It seems probable that a great variety of lesions, many of which are 
apparently slight, may produce this disease. 

Symptoms. — Two distinct types of epileptic seizures are met with: 
the major attacks, or grand mal, in which there are severe convulsions 
lasting from two to ten minutes, with loss of consciousness, etc.; and 
minor attacks, or petit mal, in which the convulsive movements are 
slight and may be absent, and in which the loss of consciousness is often 
but momentary. Between these two extremes all gradations are seen. 

Grand Mal. — The onset may be sudden, without premonition, or it 
may be preceded by certain prodromal symptoms known as the aura. 
The aura may be motor, such as a local spasm of the hand, face, or leg; 
or sensory, such as numbness and tingling in any part of the body, or 
some abnormal sensation rising gradually to the head, at which time loss 
of consciousness occurs. The variety of sensations described by patients 
as indicating an attack is endless. There may be a sensation in one 
finger, in the face, tongue, eye, or in any part of the body ; or the warn- 
ing may be of a general character, like a tremor or a shivering sensation, 
or a feeling of faintness. There has also been described a visceral or 
pneumogastric aura, in which there is epigastric pain, sometimes nausea, 
and a sensation of a ball in the throat ; or there may be palpitation, or 
cardiac distress. There may be general giddiness or vertigo, or a sensa- 
tion of fulness in the head ; or feelings of strangeness, or a dreamy, dazed 
condition ; and, finally, the aura may have reference to any of the special 
senses, most frequently to sight. Sparks may appear before the eyes, 
or flashes of light or color, or strange objects may be seen; or there 
may be a momentary loss of hearing; or strange sounds may be heard. 
In most cases the aura is peculiar to the individual. 

At the beginning of the seizure the face becomes pale, the pupils 
widely dilated, the eyes rolled up in their orbits and fixed. Speedily 
there is loss of consciousness. Simultaneously with these symptoms, or 
immediately following them, there occurs a violent tonic muscular spasm 



EPILEPSY 689 

to which are due the characteristic symptoms of the early part of the 
seizure, viz., the fall, cry, biting of the tongue, cyanosis, and evacuation 
of the bladder or rectum. The fall is forcible, violent; in fact the 
patient is precipitated, usually forward, and frequently suffers injury, 
never sinking down as in a faint. The head is often strongly rotated to 
one side. The position of the hands is frequently that assumed in tetany. 
The cry is a hoarse, inarticulate sound, not very loud, and is due to 
forcible expiration, owing to spasm of the muscles of respiration with 
the glottis partially closed. The cyanosis is the result of tonic spasm 
of the muscles of respiration; it may be quite intense, so that the face 
is livid, bloated, and the features distorted. The spasm of the muscles 
of mastication causes the biting of the tongue. Evacuation of the bladder 
and rectum may result from contraction of their walls, or from spasm of 
the abdominal muscles. The violence of the muscular spasm in this 
stage may be very great ; it has caused fracture of bones, rupture of 
muscles, and even dislocation of joints. 

The stage of tonic spasm may be only momentary, the patient passing 
almost at once into the stage of clonic convulsions. The usual duration 
is from ten seconds to half a minute. In the stage of clonic spasm 
which follows, the symptoms are those of an ordinary attack of con- 
vulsions. The muscular contractions are violent, and there is often 
frothing at the mouth. Gradually the muscles of respiration relax, air 
enters the lungs, and the cyanosis passes off. After the clonic spasm 
has continued for a variable time — from two to three minutes to half an 
hour — the muscular contractions become less and less frequent, and 
finally cease altogether. In a few minutes the patient may regain 
consciousness, look vacantly around, and in a dazed way perhaps ask what 
has happened, he being completely oblivious to all that has occurred. 
More frequently, however, he passes at once into a deep sleep, which 
continues for an hour or more, but from which he can be aroused. From 
this he usually wakens with a severe headache, which may continue far 
several hours. After this he often feels better than for several days 
preceding the attack. During the seizure the temperature may be 
elevated one or two degrees, but rarely more. The attack may be fol- 
lowed by a slight temporary paresis, aphasia, hysterical phenomena, 
vomiting, and intense hunger. In very rare cases the urine may contain 
a trace of sugar. 

Petit Mai. — The minor attacks of epilepsy may present a very great 
variety of symptoms, and at times it is almost impossible to decide that 
these are epileptic, except from their periodical occurrence. They pass 
under the names of "spells," "attacks of dizziness, n "fainting turns," 
etc. In recent years the term "absences" has been employed to designate 
them. The most striking thing which stamps them as epileptic is the 



690 DISEASES OF THE NERVOUS SYSTEM 

loss of consciousness, and this may be of short duration, sometimes only 
momentary, and so pass unnoticed; in some cases there is none. There 
is no fall, but there may be a slight dropping of the head, a fixed stare 
for a moment or two, and that is all. The muscles are often firmly fixed 
so that the child stands straight and stiff. Occasionally there are one 
or two contractions of the arms or a violent bending forward or nodding 
movement. These attacks may or may not be preceded by aura. After 
such a mild attack the patient's mind may be somewhat confused or he 
may become sleepy. One of the most striking things about attacks of 
petit mal is the frequency of their repetition. There may be as many 
as thirty or forty attacks a day. Petit mal is a serious form of epilepsy 
and after a time is usually associated with grand mal. 

''Equivalents" are attacks in which only an abnormal mental state is 
manifested. They may come on after an attack of grand mal or petit 
mal or they may occur with no previous attack, apparently taking the 
place of one of them. Sometimes they are the first evidence of epilepsy. 
There may be for a time a complete alteration in the disposition of the 
child. He may have uncontrollable fits of anger, be disobedient or 
destructive, run away, and, in rare instances, even acts of violence have 
been committed. Upon recovery from such a state, which is usually 
sudden, there is generally no recollection of what has occurred. 

The Mental Condition of Epileptics. — A careful distinction should be 
made between cases in which epilepsy is secondary to some organic brain 
disease, and the mental disturbances seen in cases of idiopathic epilepsy. 
The children who are the subjects of the latter disease, and who are 
perfectly normal mentally, are certainly few. All degrees of disturbance 
may be seen, from those who are simply dull, apathetic, backward in 
development, and uncontrollable in temper, to those who are melancholic, 
idiotic, and even maniacal. The earlier in childhood epilepsy develops, 
the greater is usually the mental disturbance seen, because of the effect 
upon the brain during its period of active growth. Mental deterioration 
with repeated attacks of petit mal may be rapid. 

Symptomatic Epilepsy. — This occurs most frequently in children as a 
sequel of cerebral palsy, usually with hemiplegia, and it may follow 
either the congenital or acquired form. Epilepsy may come on at any 
time after the onset of the paralysis, — from a few months to five or six 
years. At first the attacks may be separated by long intervals, but they 
gradually become more frequent as time passes. The convulsions in 
posthemiplegic epilepsy begin, as a rule, on the paralyzed side, and 
for a long time they may be confined to that side ; but later they may 
become general, in which case they are indistinguishable from attacks 
of idiopathic epilepsy. Severe seizures are more likely to be seen than 
are the mild ones. Children with microcephalus often regularly suffer 



EPILEPSY 091 

from repeated convulsions that differ in no way from epileptic seizures. 

Jacksonian epilepsy consists in localized spasms of groups of muscles 
in the face, arm or leg with retention of consciousness. The most fre- 
quent lesion producing this form of epilepsy is a cerebral tumor, but 
almost any abnormal process involving the cortex may be the cause. 
Jacksonian epilepsy is described under the diseases in which it may be 
found. 

Course of the Disease. — In most cases seizures at first occur at long 
intervals, of perhaps a year, but later they become more and more fre- 
quent. Either the mild or the severe attacks may be first seen, and may 
remain throughout as the only type present, or they may be associated 
in the same case. There are most frequently seen occasional major 
attacks with a large number of minor ones. The interval between the 
epileptic seizures in most cases is from two to four weeks, although they 
may be of daily occurrence. Sometimes three or four seizures will follow 
one another closely, and then there will occur a long interval. The 
seizures may come on either during sleep or in the waking hours, and 
in some cases for a long time they may occur only in sleep. Such cases 
present peculiar difficulties in diagnosis, and are often long unrecognized 
as epileptic. The general health of patients may be quite normal. 

Death rarely, if ever, results from epilepsy, except from some accident 
at the time of the seizures, or from the condition known as status epUep- 
ticus; in this the attacks come on with great frequency and severity, the 
patient at times passing rapidly from one convulsion into another, the 
temperature rising to 105° or 106° F., and death occurring either from 
exhaustion or in coma. 

Diagnosis. — In most cases there is little difficulty in recognizing the 
major attacks when they occur by day. Nocturnal attacks may be diag- 
nosticated by the cry, the biting of the tongue, blood upon the pillow, 
sub-conjunctival extravasation, evacuation of the bladder or rectum, and 
the severe headache. Minor attacks present the greatest difficulties, and 
a positive diagnosis is often impossible until the patient has been watched 
for a long time. The most important points to be noted are sudden 
pallor, dilatation of the pupils, temporary loss of consciousness, or simply 
mental confusion, and sometimes the evacuation of the bladder. Psychic 
equivalents can only be suspected unless there is a history of attacks of 
grand or petit mal. 

It is not always possible to distinguish between secondary or symp- 
tomatic epilepsy and the idiopathic or hereditary form, particularly if 
the case comes under observation late in the course of the disease. The 
points which go to establish the first form arc: thai the convulsive move- 
ments are partial, or limited to one side; that when they air general, 
they always begin in the same part of the body; or thai there is a history 



692 DISEASES OF THE NERVOUS SYSTEM 

of partial or unilateral attacks for some time before the occurrence of any 
general convulsions. It is important in all cases to examine the patient 
carefully for signs of an old hemiplegia, the symptoms of which may 
be so slight as to be readily overlooked. A marked increase in the reflexes 
of one side is quite as conclusive evidence as is a distinct weakness of the 
arm or leg. In idiopathic epilepsy some of the stigmata of degeneration 
are usually present. The sudden development of epileptiform seizures in 
a child previously healthy, and in whom there is no hereditary history of 
the disease, should always arouse the suspicion of some organic brain 
disease, especially tumor. 

Prognosis. — The danger to life in epilepsy is very slight. Death is 
generally due to some accident, particularly drowning, at the time of a 
seizure. The tendency to spontaneous cessation of the attacks is small, 
while the tendency to recurrence is very great. It should be recognized, 
however, that instances are not infrequently met with in which appar- 
ently clear cases of epilepsy recover. This may happen without any treat- 
ment. This is more common when the attacks have been of the grand 
mal type but even petit mal may cease spontaneously. The attacks may 
gradually become less and less frequent or may cease suddenly without 
recurrence. 

The prognosis in any given case depends upon the cause of the dis- 
ease and the duration of the symptoms. When the cause can be removed, 
which is infrequently the case, and when the symptoms have lasted less 
than a year, the prospects of permanent cure are fairly good. If an 
hereditary tendency to the disease is marked, if the epileptic seizures 
have developed apart from any adequate exciting cause, and if they have 
continued untreated or in spite of treatment for two or three years, the 
symptoms may perhaps be relieved, but there is little prospect of per- 
manent cure. In the cases also which are due to local irritation, like 
that resulting from an old meningeal hemorrhage, the prognosis is 
invariably bad, and only temporary relief is to be expected. A few cases 
of traumatic epilepsy have been cured and many have been greatly im- 
proved by a surgical operation. 

Treatment. — The general hygienic and dietetic measures are of equal 
importance with the use of drugs. The most common mistake is to rely 
only upon drugs, ignoring the other measures mentioned. It not infre- 
quently happens that drugs are without any effect when they are the 
only means of treatment employed, whereas in conjunction with other 
measures marked improvement is seen. The general hygiene of the 
patient must receive careful attention. He should lead a simple, regular 
life, as much as possible out of doors, away from all sources of excite- 
ment. Particular attention should be given to the digestive organs. 
Meat should be allowed once a day and in moderate quantity. Milk 



EPILEPSY 693 

should be given, also buttermilk or kumyss. Green vegetables, peas and 
beans, may be given freely ; also all fresh fruits. Tea, coffee, and alcohol 
in every form must be absolutely prohibited. Under no circumstances 
should a condition of chronic constipation be neglected. 

Evidences of syphilis, in the history, by physical examination and 
by the Wassermann reaction should be carefully sought. If these are 
present or if there is .only a suspicion that syphilis may be the cause a 
thorough trial of antisyphilitic treatment should be made. 

The bromids are unquestionably the best means of combating the 
epileptic habit. Either the sodium salt alone or a combination of the 
sodium and ammonium bromid is to be preferred. The purpose should 
be to give the smallest doses which will control the seizures. Children 
require proportionately larger doses than adults, and in most cases a 
child of five years will need from twenty-five to fifty grains a day. The 
method of administering the bromids is of some importance. The larger 
part of the quantity for twenty-four hours should be given shortly before 
the time when the seizures have usually occurred; in the interval much 
smaller doses. In most cases it is desirable to give a full dose at bedtime. 
Bromids should always be given largely diluted — in from three to four 
ounces of water. It is believed by many that more satisfactory results 
are obtained with the bromids and a smaller quantity required if the 
sodium chlorid in the diet is restricted to a minimum. A combination of 
opium with the bromids is warmly recommended by some authors. The 
opium must be given in full doses and preferably for some days or weeks 
before giving the bromid. 

Cases of petit mal are especially difficult to control. For such there 
is often an advantage in combining belladonna with the bromids. In all 
cases the treatment must be continued for a long time if anything is 
accomplished. The bromids should be gradually reduced after the attacks 
are controlled, but must be given in moderately large doses for at least 
two years after the seizures have ceased. Sometimes the combination 
of chloral or antipyrin with bromids is advantageous, particularly if the 
latter are badly borne or cause an annoying amount of acne. Cases 
have been reported of very striking benefit following the use of calcium 
lactate. It is deserving of trial and should be given in full doses, at 
least thirty grains a day for a considerable period. 

The surgical treatment of epilepsy has of late attracted much atten- 
tion. An operation is to be considered in cases in which the paroxysms 
are very frequent and severe, when they arc limited entirely or chiefly to 
one side of the body and when there is present a definite local cause. 
such as an old fracture of the skull, or when epilepsy has followed an 
injury to the head even without fracture. The results of operation are. 
in many instances, disappointing. There may be a diminution of the 



-694 DISEASES OF THE NERVOUS SYSTEM 

attacks for a time, but they usually recur. There are sufficient instances 
on record, however, of permanent improvement or even definite cure to 
warrant operative procedure for very frequently repeated epileptic at- 
tacks, especially if there are any evidences of localization of the lesion. 
Status epilepticus requires prompt and active treatment. A high cleans- 
ing enema should be given followed by chloral and bromid by rectum in 
full doses. Morphin hypodermically, or veronal in full doses, trional or 
amylene hydrate by mouth may be given in addition. 

The education of epileptic children is a subject of great difficulty 
and is often neglected. There are many reasons why it is impracticable 
to send them to ordinary schools, and it is therefore very desirable that 
special schools and colonies for them should be established. 

The Management of the A t ta ck.— Abortive measures are sometimes 
successful in cases with a distinct aura, the most reliable being the in- 
halation of nitrite of amyl. While the seizure lasts, the patient should 
be prevented from injuring himself. The clothing should be loosened, 
a spool or cork should be placed between his teeth to protect the tongue, 
but no effort made to restrain his movements unless he is likely to do 
violence to himself. An epileptic child should never be without some 
companion. 

CHOREA 

(Saint Vitus' s Dance) 

Chorea is a functional nervous disease characterized by aimless, 
irregular movements of any or all the voluntary muscles. Choreic move- 
ments are of a somewhat spasmodic character, often accompanied by an 
apparent or real loss of power in the groups of muscles affected, and 
by a mental condition of extreme irritability. 

Etiology. — Chorea is most frequently seen between the ages of seven 
and fourteen years. Of 146 cases, 6 were under five years, 72 between 
five and nine years, and 68 between ten and fourteen years. The young- 
est case of which Ave have records was that of a child four years old. 
It is extremely rare before the third year, although it may occur even in 
infancy. Our own observations coincide with those of nearly all writers, 
that the disease is more than twice as frequent in females as in males. 
While chorea may be seen at all seasons, it is much more frequent in the 
spring months. Of 717 attacks studied by Lewis (Philadelphia), the 
largest number began in March, and the next largest number in May; 
in our own cases May stands first. 

The relation of chorea to rheumatism is of much importance. The 
investigations of different writers have given results which are somewhat 



CHOREA 695 

contradictory. Some have found evidences of rheumatism in but a small 
proportion of the cases — in not more than five or ten per cent — while 
the statistics of others have placed the percentage with rheumatism as 
high as fifty or even sixty per cent. The question hinges largely upon 
what is to be admitted as evidence of rheumatism in a child ; if cases of 
acute articular inflammation only, then the number will be very small ; if 
subacute cases with joint swellings are included, the proportion will be 
considerably larger ; while if we admit cases of acute endocarditis without 
articular symptoms, and those of articular pains and joint stiffness but 
without swelling, the proportion will be very much increased. Our own 
belief is that there is a very close connection between chorea and the 
rheumatic diathesis as manifested by all the symptoms above noted, and 
accompanied by a family history of rheumatism. There seems to be a 
large group of cases, therefore, which may be classed distinctly as rheu- 
matic. There are, however, a few others in which no such element can 
be found. 

Crandall has analyzed 146 cases of chorea treated in an out-patient 
clinic and in private practice, with the following results: Of 111 cases 
in which the question of rheumatism was investigated there was a definite 
history of it in 63. In 41, articular symptoms occurred before the chorea; 
in 13, the first evidence of rheumatism was coincident with the chorea; 
and in 9 it first occurred subsequent to the chorea, usually within three 
months. In about one-third of the cases, attacks of rheumatism occurred 
during or subsequent to the chorea as well as before it. It may then be 
stated that previous rheumatism was evident in 37 per cent, concurrent 
rheumatism in 24 per cent, and subsequent rheumatism in 15 per cent 
of the cases. Excluding cases mentioned twice, and also all those in 
which there was a history only of "growing pains," there was evidence 
of articular rheumatism in 56.7 per cent of the cases. Many of these 
patients were under observation for several years, and it was interesting 
to see, as time passed, how the evidences of rheumatism multiplied the 
longer the cases were followed. 

In the above statistics only articular symptoms have been accepted 
as evidence of rheumatism. If the cases of endocarditis without articular 
symptoms were included, as they might fairly be, it would raise the 
proportion of rheumatic cases -till higher. The great proportion of 
constant cardiac murmurs persisting after chorea, if not all of them, 
should be classed as rheumatic, even if no articular symptoms have been 
present. 

Overpressure in school is often an important element in the produc- 
tion of chorea. Anemia, if not an essentia] factor, is certainly a very 
important one, and the great proportion of cases present very distinct 
evidences of it. Chorea may develop as a sequel of any of the infectious 



690 DISEASES OF THE NERVOUS SYSTEM 

diseases, more particularly scarlet and typhoid fevers. Among the reflex 
causes that have been suggested, but whose influence is doubtful, may be 
mentioned phimosis, either lumbricoids or pinworms, delayed menstrua- 
tion, and ocular defects. The latter frequently cause a local spasm of 
the muscles of the eyes, which can hardly be considered choreic. Hered- 
itary influence is of considerable importance in the production of chorea. 
It is much more frequent in children of neurotic families, and very 
often several successive generations, or several children in the same fam- 
ily, may suffer from the disease. 

The exciting cause of chorea in a certain proportion of cases is fright ; 
occasionally it arises from imitation, and the disease has been known to 
occur epidemically in institutions. 

The role of bacteria in the production of rheumatic chorea is still 
unsettled. The organism which Poynton and Paine have described as 
the cause of acute articular rheumatism has been found in the meninges 
of the brain in a few fatal cases of chorea, but in three of our own it was 
impossible to obtain any growth from the brain or other organs. 

Pathology, — The exact pathology of chorea is at the present time not 
settled. The seat of the morbid process is undoubtedly the central 
nervous system, probably the motor areas of the cortex. The cases asso- 
ciated with rheumatism are now generally regarded as of infectious 
origin. In some severe cases which were fatal, owing to association with 
acute endocarditis, capillary emboli have been found in the brain. How- 
ever, it is by no means established that this is the condition present in 
most of the rheumatic cases. The fact that in the great majority of such 
eases complete recovery occurs in the course of a few weeks or months, 
speaks strongly against any important structural change in the nervous 
centers. 

Symptoms. — An attack of chorea generally comes on gradually. At 
first the child may be considered simply as unusually nervous; if at 
school, there may be noticed a difficulty in writing, drawing, or in using 
the hands for other delicate operations. At home, the child is con- 
tinually dropping things, has difficulty in feeding himself, sometimes in 
buttoning his clothes, and very frequently he is not brought to the 
physician until the symptoms have lasted a week or two. Sometimes the 
legs are first affected, and a history is given of frequent falls, a stumbling 
gait, difficulty in going upstairs, etc. At other times the spasm is first 
seen in the facial muscles, with disturbance of articulation, twitchings of 
the eye muscles, and the child may be punished for making grimaces. In 
most cases the spasmodic movements soon extend to all parts of the body. 
They remain limited to one side of the body (hemichorea) in about one- 
third of the cases. When fully developed, the movements of chorea are 
quite unmistakable. They are irregular, jerking, spasmodic, never 



CHOREA G97 

rhythmical, rarely symmetrical, and vary in intensity from an occasional 
muscular contraction to almost constant motion. The movements are 
not under the control of the patient's will, and are usually intensified by 
efforts to repress them. They are increased by excitement, embarrass- 
ment, or fatigue, but do not continue during sleep. 

Very often there is weakness of the affected muscles, which may be 
so great as to lead to the suspicion that actual paralysis exists. Not 
infrequently we have had patients brought to the clinic for supposed 
paralysis, either of one extremity or of one side of the body, where the 
choreic movements have not been severe enough to attract the attention 
of the mother. This paralysis usually disappears in the course of a few 
weeks. 

In severe forms of chorea the patient may be unable to walk, to speak 
intelligibly or even to sit up in bed. The movements may be so violent 
that it is necessary to pad the bed and to wrap the child's extremities 
in cotton. Control of the bladder or rectum may also be lost. The symp- 
toms may be so intense as even to threaten life. Such cases, however, are 
usually dangerous, not from the choreic movements, but from the acute 
endocarditis with which they are frequently associated. We have seen 
fatal cases, however, in which the outcome was not determined by the 
endocarditis. The temperature usually rises to 103° F. or more and 
remains constantly high. The choreiform movements are almost 
impossible to control even with sedatives in enormous doses, and 
death takes place after several days, apparently as the result of exhaus- 
tion. 

The mental condition of choreic patients is one of marked irritability. 
They are fretful, emotional, easily provoked to tears or laughter, and 
difficult to control. In extreme cases a mental disturbance bordering 
upon acute mania has been observed. In other cases the facial expression 
find manner of speech strongly suggest beginning imbecility. All degrees 
of speech disturbances are seen from the slight difficulty in articulation 
due to inability properly to control the movements of the tongue and 
lips, to a condition in which speech is almost impossible. In severe cases 
speech may be temporarily lost. 

Cardiac murmurs are frequent in chorea. Some of these are of 
anemic origin, but a large number, probably the majority, are (\uo to 
concurrent endocarditis, as is shown by the fact that they are permanent, 
and are followed by all the signs of organic heart disease. During every 
attack the heart should be closely watched, especially in children in whom 
there is a strong predisposition to rheumatism. 

The general condition of choreic patients is usually much below nor 
mal. They are anemic; the appetite is poor, often capricious; they sleep 
very badly; they suffer frequently from headaches; they are easily fa- 



698 DISEASES OF THE NERVOUS SYSTEM 

tigued by slight muscular exertion ; and in short they have all the symp- 
toms of a greatly disturbed nutrition. 

Course and Duration. — The ordinary form of chorea tends to spon- 
taneous recovery in from six to ten weeks. Exceptionally it may last for 
three or four months. In a small number of cases the disease may 
continue for a much longer period with remissions and exacerbations. 
Certain forms of local spasm, particularly choreiform movements of the 
muscles of the face, eyes, or neck, may be permanent. In any case of 
chorea which lasts longer than the usual time, the patient should be 
carefully examined for some cause of peripheral irritation. The tendency 
to relapses and second attacks is very marked. Later attacks are likely 
to occur in the spring succeeding the first illness, and in a small number 
of patients attacks may come every year for four or five years. 

Diagnosis. — There is little difficulty in recognizing chorea from the 
sudden, irregular, spasmodic contraction of the muscles coming on under 
other circumstances. No other movements of childhood are likely to be 
confounded with it. The form of chorea following hemiplegia is usually 
more athetoid than choreic, yet at times it closely simulates ordinary 
chorea. The difficulty in distinguishing between the two is often in- 
creased by the fact that the weakness of simple chorea may, if unilateral, 
closely simulate hemiplegia. The existence of rigidity, contractions, and 
increased reflexes belongs exclusively to hemiplegic cases, and these will 
usually suffice to clear up all doubt with reference to the diagnosis. 

Prognosis. — As a rule, this is favorable, and complete recovery can 
usually be predicted, the exceptions being few in number. Parents should 
always be warned of the tendency of the disease to return in succeeding 
years, and the fact should be stated that in a certain proportion of cases 
the disease may be of exceptional duration. The prognosis of the cardiac 
murmurs occurring in chorea should always be guarded, although some 
of these are functional and disappear with recovery from the chorea; 
but the number of those which do not disappear is very large and suffi- 
cient to make one always apprehensive as to the ultimate result. Acute 
chorea may be fatal from the accompanying endocarditis and much more 
rarely from the severity of the disease itself. 

Treatment. — The general management of the case is equally im- 
portant with the administration of drugs. A child with chorea should at 
once be taken from school, and should never be subjected to punishment 
or to ridicule on account of the movements. Special attention should 
be given to the patient's diet and general nutrition. Tonics, especially 
iron, are indicated in most cases. The food should be simple and nutri- 
tious, and all stimulants, particularly tea and coffee, should be absolutely 
prohibited. While fresh air is desirable, exercise should be prescribed 
with great caution and its effect should be carefully watched. A certain 



CHOREA GOO 

amount of moral restraint is indispensable; thus it often happens that 
choreic patients do very badly at home where they are indulged and 
receive sympathy, while in a hospital, where they are under restraint and 
made to control themselves, they begin to improve immediately. In all 
severe cases the rest treatment should be employed. It is equally bene- 
ficial in the milder ones ; the patient is put to bed, and complete mental 
and physical rest secured. This may be combined with gentle massage 
for fifteen or twenty minutes a day. The daily use of prolonged warm 
baths, either alone or in conjunction with massage, is at times decidedly 
beneficial. In other cases the regular use of cold douches is of value. 
t In estimating the value of drugs in the treatment of chorea, the 
natural course of the disease should be kept in mind, since those drugs 
which are taken after the third or fourth week are much more likely to 
be thought beneficial than those used in the early period of the attack. 
On account of the close association of chorea with rheumatism, anti- 
rheumatic remedies (sodium salicylate, aspirin, etc.) have very frequently 
been tried, especially in cases with fever and endocarditis and when joint 
symptoms supervene in the course of an attack. Our experience has 
been that they rarely have very much effect upon the course of the 
disease. They may alleviate the pain of acute arthritis somewhat and 
in large doses may reduce the temperature, but they exert little influence 
upon the severity or duration of the symptoms of chorea. 

Arsenic was long, and still is, regarded by some as a specific for 
the disease. The usual method of administration is to begin with four 
drops of Fowler's solution three times a day for a child of eight years, 
and to increase the daily quantity by one drop every two or three days 
until eight drops are given at each dose. One should stop short of this 
if digestion is disturbed, or there is puffmess of the face or albumin in 
the urine. Arsenic should always be given after meals, and largely 
diluted. The possibility of arsenical poisoning should be remembered, 
although it is rare. "We have known of several cases in which multiple 
neuritis developed after a few weeks' administration of the drug. In 
our hands arsenic has not been very effective against chorea. 

Severe chorea requires sedatives. Not only do they relieve the symp- 
toms but in many instances apparently have a distinct influence in 
shortening the duration of an attack. They must be given in quantities 
sufficient to produce an effect and the amount required is often enor- 
mous. The bromids, chloral, opium or morphia and veronal will he 
found the most etficacious. The bromide not infrequently must he sus- 
pended on account of eruptions. Morphin, hypodermically, is ;ii times 
the most satisfactory drug. Improvement is Bhown by a diminution of 
the amount required to produce quid but the above drugs must some- 
times be continued for many weeks. 



700 DISEASES OF THE NERVOUS SYSTEM 

Chorea has a strong tendency to recur, especially in the spring 
months. Children who have had one attack should be closely watched) 
particularly with reference to their work in school. They should not be 
crowded in their studies, they should have long vacations, and the nervous 
system should not be put upon any severe tension for a long time. 



OTHER SPASMODIC AFFECTIONS 

Habit Spasm. — This term is used to describe certain spasmodic mus- 
cular movements which at first are only occasionally noticed, but which 
may persist until they become habitual and almost entirely involuntary. 
The movements usually affect the muscles of the face, but they may be 
seen in almost any part of the body. The most frequent varieties consist 
of blinking or sudden frowning, raising the eyebrows, grinding of the 
teeth, or some peculiar grimace. At other times there is sudden twisting 
of the head, shrugging of the shoulders, or jerking of the hands. Habit 
spasm is not often seen in the lower extremities, but the muscles of 
respiration are quite frequently affected. There may be a half-sigh,' a 
sort of sob, or a peculiar dry, pharyngeal cough. 

These movements are at first infrequent; but as the habit becomes 
more firmly fixed the spasm recurs every few minutes, and in severe 
cases it may be almost continuous. The form of spasm is not always 
the same; one may disappear and another take its place. The condition 
may last for months or years, and it may even be permanent. 

Habit spasm is really little more than exaggerated nervousness con- 
tinuing in some definite form until by repetition a fixed habit is estab- 
lished. It is different in cause, course, prognosis, and treatment from 
chorea, with which, however, it is often confounded. 

The causes are those of neuroses in general. In the beginning, at 
least, the general health is usually below the normal. The patients are 
nervous children of neurotic antecedents. There may be a history of 
some definite exciting cause, such as illness or overwork in school. 
There is frequently some local cause of which the spasm is merely a 
reflex. 

Habit spasm is to be differentiated from chorea ; this is usually easy, 
from the limitation of the movements to one part or group of muscles 
and from the duration of the disease. 

Treatment is quite unsatisfactory after the habit has become fixed, 
hence it is of very great importance that it should be arrested at the 
earliest possible age. Punishments are of no avail, and usually aggravate 
the condition. Rewards are much more effectual. The child's surround- 
ings, work and study should be carefully investigated. Any local cause 



SPASMODIC AFFECTIOXS 701 

which can be discovered should be removed. Especially should the gen- 
eral health receive attention. 

Athetosis and Athetoid Movements. — These terms, introduced by 
Hammond, are used to describe a chronic form of spasm usually seen in 
the hand, but sometimes also in the foot, an.d even the face. It may affect 
both sides, but in most cases it is unilateral. The movement is slow, 
irregular, and incoordinate — a sort of "mobile spasm," it has been called 
— and there may be associated a certain amount of muscular rigidity. 
Such movements rarely occur in persons apparently healthy, but are 
usually seen as a sequel of cerebral palsies, generally hemiplegia. Recov- 
ery from the paralysis may be so nearly complete that the athetoid 
movements are looked upon as primary. In some cases the movements 
are more rapid and somewhat resemble those of chorea, the condition 
being sometimes classed as post-liemiplegic chorea. Athetosis is not in- 
fluenced by treatment. 

Rotary and Nodding Spasm of the Head. — These are rare forms of 
irregular movements usually observed in infancy. The condition was 
described long ago by Henoch. The most frequent is the rotary spasm, 
which consists in a side-to-side oscillation of the head, which may be 
slow or rapid, and in some cases is almost continuous. Some children 
have at times the nodding spasm also, and in others this is the only 
movement seen. Nystagmus is frequently associated, and may affect one 
or both eyes. In a few of the reported cases convergent strabismus was 
present. 

The causes of the condition are extremely obscure. It is usually seen 
in infancy between the third and eighteenth months. It is believed by 
Raudnitz to be often the result of living in poorly lighted rooms, it being 
necessary for the infant to assume an unnatural position of the head in 
order to see things held before him. The nystagmus is regarded as anal- 
ogous to that which develops in miners. While this explanation is satis- 
factory for some cases that are cured by being placed in well-lighted 
rooms, it is not applicable to all. 

As a rule, the condition lasts for several months and improves, 
recovery almost always taking place. The prognosis is therefore fa- 
vorable. 

Nystagmus. — This term is applied to rhythmical, involuntary, oscil- 
latory movements usually of both eyes. They arc caused by the alter- 
nate contraction of opposing muscles. Nystagmus may be either vertical 
or lateral. It is most often seen in infants a few months old. In 
some cases the movement is almost continuous, occurring even in sleep: 
in others, it is only noticed at times of special excitement. 

The etiology of nystagmus is obscure, and it may occur In quite a 
variety of conditions — sometimes referable to the eye, ;il oilier times to 
24 



702 DISEASES OF THE NERVOUS SYSTEM 

the central nervous system. On the part of the eye, nystagmus may be 
due to blindness from any cause, to congenital cataract, corneal opacity, 
disease of the choroid or retina, or to errors of refraction. It may be 
seen in almost any organic disease of the nervous system, both with focal 
and diffuse lesions, especially in chronic hydrocephalus, insular sclerosis, 
tuberculous meningitis, and in diseases in which sight is impaired. 
While it is of no importance as a localizing symptom, nystagmus often 
indicates something more than functional disturbance. An exception to 
this may perhaps be made when it follows cerebral concussion. In such 
cases it is usually temporary, disappearing in a few days or weeks. Under 
other conditions it may continue indefinitely. 

The condition of the eyes should be investigated in every case of 
nystagmus; it is only when the cause is here, and can be removed, that 
habitual nystagmus is amenable to treatment. 

Hiccough (Singultus). — This is a spasm of the diaphragm which is 
usually seen in young infants. In them it is in most cases due to some 
irritation in the stomach, but is found in perfectly healthy infants with 
no digestive disturbance. It is seen after eating, and may depend upon 
overfilling of the stomach with food, swallowing of air, etc. In other 
cases it has no relation to the taking of food. In cases like the above, 
hiccough, though sometimes annoying, is of little importance. It may 
be associated with indigestion, with intestinal flatulence or inflammation, 
with peritonitis or with intestinal obstruction. With the last two condi- 
tions it is always an unfavorable symptom. In older children hiccough 
sometimes occurs as a pure neurosis. 

The object of treatment is to remove the cause. In infants this is to 
aid in the expulsion of the gas from the stomach by manipulation or 
position. When it is a nervous symptom only, it may be arrested in 
older children by holding the breath, or by prolonged forced expiration, 
as in blowing a trumpet. 

Thomsen's Disease (Congenital Myotonia). — This rare disease is 
usually congenital. It may occur in several members of the same family, 
and is almost always hereditary. The characteristic symptoms are a 
peculiar rigidity of the muscles which is observed when they are first- 
brought into action after repose. This rigidity is spasmodic, and usually 
continues but a few moments. It may recur when voluntary movements 
are again attempted. If, however, muscular effort is persisted in, it 
soon passes off. It is increased by apprehension, excitement, or cold, and 
by observation. The legs are most frequently affected, the condition 
being often noticed when the patient starts to walk ; any of the voluntary 
muscles, however, may be involved, even the tongue. It may be greater 
upon one side of the body than upon the other. The tendon reflexes are 
not increased but there is a marked and very prolonged contraction of the 



SPASMODIC AFFECTIONS 703 

muscles as a result of direct mechanical stimulation. The electrical 
stimulation of the nerves causes generally normal or diminished contrac- 
tions; that of the muscles directly, either with the faradic or galvanic 
current, causes a contraction that remains for from ten to twenty sec- 
onds. The disease may be noticed very early in life and it generally 
increases in severity about the time of puberty. Thereafter it remains 
stationary, or nearly so. It never causes death but is incurable, al- 
though the symptoms may be improved somewhat by active muscular 
exercise. 

The muscle fibers are increased in size and the nuclei much increased 
in number. There are no evidences of degeneration, but in the sarco- 
plasm may be seen a large number of small, round, colorless or yellowish 
dots that seem to indicate actual disease of this substance. Something 
can be accomplished by massage and muscular exercises to diminish 
the tendency to muscular rigidity, but nothing approaching a normal 
condition can be brought about. 

Torticollis — Wry-Neck. — Torticollis may be congenital or acquired. 
Eegarding the cause of congenital torticollis there is some dispute. Such 
cases have often been attributed to the contraction resulting from hema- 
toma of the sternomastoid. It is our belief that this is rarely, if ever, 
the case. While it is possible that the deformity is sometimes the con- 
sequence of injury received during delivery, the cause of most of the con- 
genital cases goes back to conditions existing before birth. It may be 
compared to club-foot, and may be due to a faulty position of the child 
in utero. There may be a congenital shortening of the sternomastoid 
muscle alone or of several muscles, or of all the tissues on one side of the 
neck. Very rarely congenital torticollis is the result of anomalies of oik; 
or more cervical vertebrae. The most frequent cause in the acquired 
cases is inflammations of the neck, the result of tonsillitis and pharyn- 
gitis. Such is the usual etiology of torticollis following scarlet fever, 
measles, or diphtheria. The exciting cause of the spasm is irritation of 
the cervical nerves, usually the spinal accessory, though others also may 
be involved. 

Torticollis is seen with cervical adenitis, acute or tuberculous, and 
with cellulitis of the neck. Indeed, it may be the result of anything 
causing irritation of the trunk or branches of the spinal accessory nerve, 
either in the spinal canal, the cranium, or along the course of the nerve 
trunk or of any of its peripheral fibers. Most of the cases thai have 
been described as the result of rheumatism and cold are probably due In 
infections occurring through the tonsils and pharynx. A cause which 
the physician should always have in mind is cervical Pott's disease; tor- 
ticollis may be the earliest, and for several weeks sometimes almost 
the only objective symptom of this disease. Infrequent causes of tor- 



704 DISEASES OF THE NERVOUS SYSTEM 

ticollis are acute inflammation of the suboccipital articulations, uni- 
lateral dislocation, osteo-arthritis of the cervical spine and cervical 
rib. 

The onset may be acute and accompanied by fever, or what is more 
frequent is that the torticollis gradually develops, it being several days 
or weeks before it is marked and permanent. The deformity varies some- 
what, according as the sternomastoid muscle is alone affected, or the 
posterior muscles also, and as to which predominates. In simple sterno- 
mastoid spasm the head is inclined to the affected side and rotated toward 
the opposite side ; the chin is raised, and the ear approaches the clavicle. 
When other muscles are involved the deformity is modified. If the 
trapezius is affected there is less rotation of the head, but it is drawn to 
the affected side and somewhat backward, while the shoulder is raised 
and the spine curved. Both of these symptoms may be seen to a slight 
degree in almost any marked case of sternomastoid spasm. Sometimes 
the spasm of the posterior muscles affects both sides; the head is then 
drawn backward and held rigidly, but without rotation. In recent cases 
the deformity can be partially or entirely overcome by passive force; 
but after a time this is impossible, owing to muscular shortening. 
Atrophy may take place in the affected muscle. In recent cases local- 
ized pain and tenderness are also frequently present, and sometimes 
they are severe. Attempts to reduce the deformity may produce great 
pain. 

Prognosis. — The result in a case of torticollis depends upon the cause, 
the severity and the duration of the deformity. Kecovery in most of the 
acute cases is complete in the course of a few days or weeks. In others, 
after the subsidence of the symptoms of local inflammation there may 
be no tendency to a reduction of the deformity. This, if untreated, may 
be permanent, owing to shortening of the muscles and fascia. The con- 
genital cases with slight deformity are usually amenable to mechanical 
or postural treatment if begun early. There is in most of the other 
varieties a disposition for the deformity, if untreated, to persist, and 
even increase. If it has lasted several months the probabilities of spon- 
taneous recovery or even of improvement are small. 

Treatment. — The first indication is to remove or treat the cause when 
one can be found. Acute cases are to be treated by rest in bed, hot appli- 
cations, counterirritation and friction, unless the pain is too severe. 
Cases which have lasted a month usually require some orthopedic head- 
support, and those which have lasted six months or more are rarely cured 
without a surgical operation. This may be either a subcutaneous 
tenotomy or myotomy of the sternomastoid, or an open incision. An old 
case of torticollis is a serious matter and radical measures should be 
resorted to early in the disease. 



HYSTERIA 705 



HYSTERIA 



This is not a disease of childhood, but one which is occasionally 
seen in early life. All that will be attempted in this chapter is to point 
out the most common manifestations of hysteria when it occurs in chil- 
dren. After puberty it is essentially the same as in adults. 

Etiology. — Hysteria is very rare before the seventh or eighth year, 
and most cases seen in children occur after the tenth year. As to 
sex, there is no such predominance of females as in later life, although 
even in childhood they are more frequently affected than males. Hered- 
itary influences play an important part in the production of this disease. 
It is seen in children who inherit a nervous constitution, or in whose 
parents nervous diseases, such as insanity, or hysteria, or neurasthenia, 
have been present. Of the other etiological factors the most important are 
a disordered nutrition, frequently with anemia or chlorosis, and over- 
pressure in schools. Masturbation may act as an exciting cause, or, 
indeed, anything which leads to an exalted nervous irritability and depre- 
ciation of the general health. It may follow any of the acute infectious 
diseases; or it may be excited by injury, fright, or imitation. 

Symptoms. — There is scarcely any disease in which the clinical pic- 
ture presented is so varied as in hysteria. It may simulate almost any 
form of organic disease of the brain, lungs, digestive organs, bones, or 
joints. The symptoms are seen in almost every conceivable combination. 

Psychical symptoms frequently predominate. There may be seen 
periods of mental depression of longer or shorter duration, a change 
in disposition, an indifference to surroundings, a capricious humor, or a 
nervous condition of extreme irritability with irregular paroxysms of 
laughter or weeping without cause. There may be great excitability of 
temper, and fits of passion almost maniacal in their severity. There 
may be various hallucinations. Sleep is frequently disturbed, some- 
times by attacks resembling ordinary night-terrors; sometimes somnam- 
bulism is present. There is often a disposition to deception about tbe 
most trivial matters, which may last for weeks. There is a tendency to 
imitate the symptoms of various diseases, which the patients may have 
witnessed in others or about which they have read. Sometimes the 
special senses are affected, giving rise to hysterical blindness or deafness, 
usually of short duration. 

Sensory symptoms are the most frequent manifestations of hysteria 
in early life. There is often general or local hyperesthesia, which may be 
so great as to simulate inflammation of the various internal organs. 
Anesthesia is much less common, although it may be seen in children as 
young as eight or nine. Anesthesia is very frequently associated with 



706 DISEASES OF THE NERVOUS SYSTEM 

paralyses. In such circumstances it is apt to involve the whole of 
one or more extremities and in such a way as to be inexplicable by any 
organic lesion. Paralysis is an infrequent but striking symptom. There 
may be monoplegia or paraplegia, more rarely hemiplegia or paral} T sis 
of all four extremities. There may even be edema and a certain degree 
of atrophy of the affected extremity from disuse. The inability to stand 
or walk, though the legs can be moved perfectly in the recumbent posi- 
tion, is observed at times. Headache is an occasional symptom, and is 
sometimes associated with great tenderness of the scalp. There may be 
neuralgias in the different parts of the body, or sharp pain, sometimes 
accompanied by vomiting. 

Joint symptoms are really a variety of sensory disturbances. They 
are not uncommon, and are often most puzzling. All forms of organic 
disease of these joints may be simulated. Joint symptoms are usually 
seen between the ages of ten and fourteen years, and occur in both sexes. 
There may be lameness referred to one of the large joints, curvature of 
the spine, or torticollis. The symptoms are most frequently referred to 
the hip, and next to the knee, the ankle, or the spine. The pain is acute. 
It is increased by motion, and by attempts at overcoming the deformity, 
if any is present. There is a marked hyperesthesia of the whole limb, 
and sometimes of the body. The resistance and pain caused by passive 
motion are often greater than in most joints, which are the seat of or- 
ganic disease. In nearly every case there is marked tenderness of the 
spine upon pressure, especially in the dorsal region. The deformity 
may be very slight from spasm of the flexors only, or it may be severe, 
and followed by contracture, so that the thighs may be flexed tightly 
against the abdomen with the heels against the buttocks. Such de- 
formities may last for months. There may be considerable muscular 
atrophy, but only that which comes from disuse. A special difficulty in 
diagnosis arises from the circumstance that these symptoms occasionally 
follow an injury. 

Organic disease of bones and joints may usually be excluded by 
attention to the following points: The mode of onset is more abrupt 
than is seen in bone disease, and the course of the disease is quite ir- 
regular. The degree of deformity is greater than is seen in bone dis- 
ease of the same duration. There is general hyperesthesia of the limb, 
acute tenderness of the spine upon pressure, and undue sensitiveness to 
heat or cold. The deformity varies from time to time, being always more 
marked when examination is attempted. If the patients are closely 
watched, other evidences of hysteria may be seen. Under complete anes- 
thesia the contractures disappear entirely. There is no enlargement 
of the articular ends of the bones, no swelling of the soft parts, and no 
evidence of active inflammation or of suppuration. All the symptoms 



HYSTERIA 707 

except the deformity are subjective. Under proper treatment there is 
in most cases perfect recovery, often in a surprisingly short time. 

Digestive symptoms are quite frequent. There may be loss of 
appetite, at times so extreme as to lead to great emaciation. There may 
be dysphagia from spasm of the esophagus, or regurgitation of food on 
attempts at swallowing. There may be troublesome hiccough. Vomiting 
is a frequent symptom. It is seldom severe. A very frequent form met 
with is that which occurs in school children before starting for school. 
Throughout the rest of the day nothing is vomited and the appetite may 
be good. Persistent diarrhea, constipation, meteorism, and incontinence 
of feces may be met with. 

In the milder forms of hysteria there are seen many varieties of tonic 
or clonic spasm. There may be local spasm of the eyes, face, or mouth, 
spasm of the muscles of the neck producing torticollis, of the muscles 
of respiration causing dyspnea, which may be constant or paroxysmal. 
Disturbances of speech are quite common especially in older children. 
There may be inability to speak above a whisper while the voice is 
retained in singing or after the application of the faradic current to 
the neck. Stuttering and stammering may be due to hysteria. Very 
rarely no attempt at phonation can be made. A very common symptom 
is hysterical cough, which may be so frequent and so severe that grave 
disease of the lungs is suspected; the chest, however, is free from the 
physical signs of disease. In more severe cases we may have the symp- 
toms of chorea major and attacks of hystero-epilepsy. The latter are 
rare in children and do not differ essentially from such attacks in older 
patients. There are usually prodromal symptoms. The convulsive move- 
ments are exceedingly varied in type. There are painful sensations and 
sensitive areas, by pressure upon which hysterical symptoms may be 
increased or even convulsions excited. The respiration may be rapid 
or irregular. All variations in tonic and clonic spasms may be 
seen. Opisthotonus is frequent. Consciousness is not fully lost, but 
is disturbed, and hallucinations are present. The temperature is nor- 
mal. 

Other symptoms occasionally seen in hysteria are polyuria, very fre- 
quent urination, sometimes incontinence of urine, and disturbance of 
the secretion of saliva or perspiration. 

The general condition of hysterical patients is usually below the nor- 
mal. They are poorly nourished and anemic; they sleep badly; they 
have capricious appetites and feeble digestion. 

Diagnosis. — Hysteria is apt to be overlooked because its occurrence 
in children is not considered as often as it should be. In most eases the 
diagnosis is easy if hysteria is suspected. A combination of vague dis- 
connected symptoms is usually present which admits of no other ex- 



708 DISEASES OF THE NERVOUS SYSTEM 

plantation. Organic disease can be excluded only by careful and repeated 
examinations. It is to be borne in mind, however, that hysteria not 
infrequently complicates organic or constitutional disease. Much im- 
portance is to be attached to a family history of hysteria or of other 
neuroses. 

Prognosis. — This is better than in adults, especially if the "cases are 
taken in hand early, before the disease has become deeply seated. Very 
much depends upon how well the directions for treatment can be carried 
out. The prognosis is less favorable when the hereditary tendency is 
strongly marked. In many cases there are relapses later in life. 

Treatment.— Prophylaxis is of much importance. When an hereditary 
tendency to nervous diseases exists in a family, or whenever very 
nervous children are placed under the physician's care, every means 
should be taken to further muscular development, keeping the nervous 
system in the background. Such children should lead an outdoor life 
as much as possible, preferably in the country. They should keep early 
hours, have regular exercise, and their education should be directed with 
moderation and judgment, special attention being paid to regularity of 
work and the prevention of overpressure in schools. Theaters and ex- 
citing books should be avoided. All stimulants, including tea and 
coffee, should be absolutely forbidden. The diet should be plain and 
nutritious. It is highly important that such children should be re- 
moved from association with an hysterical mother, when this is possible. 
The best results are usually obtained when the child is taken from his 
home surroundings and placed in some quiet retreat in charge of an 
intelligent nurse. Isolation is absolutely essential in many cases. 

In the general management of a case of hysteria, it is of the first 
importance that the child should be cared for by a person of firmness, 
who can exercise proper control. The general health should be carefully 
looked after, and arsenic, iron, cod-liver oil, and other tonics given ac- 
cording to indications. Outdoor sports should be encouraged, and every 
means taken to interest the child in something which requires physical 
exercise. In cases of simulated disease, the child should be put to bed, 
no books or toys allowed, and no effort made toward his amusement. No 
sympathy should be exhibited, but the child should be treated with kind- 
ness and firmness. This moral treatment is quite as important as any 
other part of the therapeutics. In cases with hysterical joint symptoms 
mild counterirritation to the spine, preferably by the Paquelin cautery, 
is sometimes of distinct benefit. In no circumstances should mechanical 
force be used to overcome deformity. Many cases of hysteria improve 
under hydrotherapy; the cold douche, the cold pack, or the shower bath 
may be used. This is valuable in conjunction with massage and the 
rest treatment. 



HEADACHES 709 



HEADACHES 



Headaches are not common in little children except in connection 
with disease of the brain or meninges ; in older children they occur from 
causes similar to those seen in adult life. The most frequent headaches 
ma}' be grouped in the following classes : 

1. Toxic Headaches. — Such are the headaches resulting from uremia, 
from malaria, and those seen in many acute infectious diseases. But 
the largest number are associated with disturbances of digestion. 

2. Headaches from Anemia, Malnutrition, and Nervous Exhaustion. — 
These are most frequently seen in girls from ten to fourteen years old. 
Some are intellectually bright, and have been crowded in their school 
work; others are dull and learn only with difficulty, and in consequence 
worry over their work until their health becomes undermined. They 
sleep badly, lose appetite, and often become choreic. The anemia may 
be either the cause or the result of these symptoms. 

3. Headaches of Nervous Origin. — These may occur in children who 
are highly neurotic, either from their inheritance or surroundings, and 
in those who are the subjects of epilepsy or hysteria, and they may be 
symptomatic of organic disease of the brain, such as tumor or tuber- 
culous or syphilitic meningitis. True facial neuralgia is rare in child- 
hood except from carious teeth; from this cause, however, it is not in- 
frequent. 

4. Headaches due to Disease of some of the Organs of Special Sense. 
— In connection with the eyes there may be conjunctivitis, keratitis. 
iritis, errors of refraction, or strabismus; connected with the nose there 
may be polypi, hypertrophic rhinitis, or adenoid vegetations of the 
pharynx; connected with the ears there may be otitis or foreign 
bodies in the canal. Each one of these conditions requires special treat- 
ment. 

5. Headaches due to Inherited Gout or Rheumatism. — These are not 
very frequent, but they may be severe, and may at times simulate the 
onset of meningitis. They are often accompanied by pains in the joints, 
muscles, or nerve trunks. 

6. Disturbances of the genital tract are rarely a cause of headaches in 
children, although this may be the case in girls about the time of pu- 
berty, especially when menstruation is delayed or difficult. 

Diagnosis. — The diagnosis of headaches includes the discovery of the 
cause, and this is often difficult. In an infant or a young child, organic 
disease of the nervous system should always be suspected as a cause of 
severe headaches, In older children the important things to he con- 
sidered, because the most frequent, are digestive disturbances, nervous 



710 DISEASES OF THE NERVOUS SYSTEM 

exhaustion, malnutrition, and visual disorders. An absolute diagnosis 
in a case of persistent headache can be made only by a careful physical 
examination, not omitting a study of the urine; often there must be a 
close observation of the patient for some time. 

Treatment. — The only successful treatment is that which is directed 
toward a removal of the cause. Each one of the different groups above 
mentioned is to be managed differently, according to the principles else- 
where laid down regarding the treatment of these conditions. For the 
relief of the symptoms, cold to the head, a hot foot-bath, and phenacetin 
in moderate doses are perhaps the most certain of all remedies. 



DISORDERS OF SPEECH 

In this chapter will be discussed only functional speech defects, those 
depending upon organic conditions being considered in connection with 
diseases of the brain. The most common varieties are stuttering, stam- 
mering, lisping, alalia, backwardness, and functional aphasia. All forms 
are much more frequent in boys than in girls, the proportion being more 
than four to one. 

Stuttering. — This is the most common form of speech disturbance. 
Articulation is distinct and the separate sounds are properly produced, 
but there is a difficulty in connecting the consonant with the succeeding 
vowel ; this seems like an obstacle to be overcome. Occasional stuttering 
is seen in very many children. It is more frequent in the third and 
fourth years, before speech is thoroughly mastered. At this age it is 
aggravated or produced by disturbances of nutrition, but is usually 
a temporary condition, lasting for a few weeks or months. Recently 
a little boy of four was under our care, who became very anemic, slept 
poorly, and suffered from malnutrition as a result of the confinement 
incident to a home in the city. He soon began to stutter, and in a short 
time it became painfully marked. After a few weeks in the country he 
improved very much in his general condition, gained four or five pounds 
in weight, and his stuttering completely disappeared. In other cases 
stuttering follows some acute illness, and under such conditions also it 
is usually of short duration. 

Most children who become habitual stutterers do not begin until they 
are six or seven years old, and sometimes even later. Stuttering may 
arise from imitation, and inheritance is an important etiological factor. 
It is frequently a mark of degeneration. 

It is important that all such cases receive early treatment before 
the habit becomes firmly fixed. The prognosis is good for spontaneous 
recovery in nearly all the cases seen in very young children, and also in 



DISORDERS OF SPEECH 711 

those coming on after acute illness. Other cases in which the condition 
has become habitual should have the benefit of systematic training under 
a competent teacher in breathing and vocal gymnastics. 

Stammering. — This term is sometimes used synonymously with stut- 
tering. Ivussmaul makes the distinction between them that, in stam- 
mering, individual sounds are difficult of production, while in stuttering 
it is syllabic combinations. Stammering is often accompanied by some 
defect in the organs of articulation — the teeth, lips, tongue, or palate — 
which is not present in stuttering. 

The treatment consists in careful training and in the correction of 
whatever abnormal local conditions may exist. 

Lisping. — In this there is an imperfect production of certain sounds, 
owing usually to a faulty position of the organs of articulation. The 
sounds may be so indistinct that they can not be understood. In this 
condition also there may be defective formation of some of the organs 
of articulation, although in the milder forms this is not the case. The 
treatment is similar to that of stammering. 

Alalia. — This consists in a total inability to articulate. It is seen in 
all young infants during their earliest attempts at talking. In older 
children it is not a very rare condition, being usually associated with 
some mental defect. 

Backwardness. — Backwardness is carefully to be distinguished from 
a late development of speech due to mental defects. At two years old 
children not deaf are almost invariably able to speak. Speech may be 
late in consequence of prolonged or very severe illness, and when it has 
once been acquired it may be lost from similar causes. 

Functional Aphasia. — The term has been applied to a temporary loss 
of speech which sometimes occurs in chorea, and sometimes from severe 
fright or anything else which has produced a marked nervous impression. 
West records an instance in a girl of eight years, who was suffering from 
an attack of chorea induced by fright. Speech first became difficult and 
then was lost altogether. For a month the child could say only "yes" 
and "no." The child improved very slowly, but at the end of nine weeks 
bad recovered completely. Loss of speech sometimes follows the acute 
infections diseases, especially typhoid fever. 

In all disorders of speech, the functional cases are to be distinguished 
from those which depend upon deafness and mental deficiency. The 
frequency with which these disorders are due to disturbances of general 
nutrition, and to local causes in the month and throat, should be borne 
in mind, and these conditions should receive their appropriate treat menl 
early, before the habit of defective speech becomes firmly established. 
For the latter class of unfortunates, special training at the hands of a 
competent teacher should be advised, preferably in an institution. 



712 DISEASES OF THE NERVOUS SYSTEM 



DISORDERS OF SLEEP 

Disturbed Sleep, Sleeplessness. — Disturbed or restless sleep is much 
more common in infancy and childhood than is true insomnia, although 
the causes of the two conditions may be the same. 

Etiology. — In infancy these symptoms are most frequently due to 
hunger or to indigestion resulting from overfeeding or improper feeding. 
Very often disturbed sleep is the result of bad habits, such as rocking 
during sleep or night-feeding. Sometimes it arises from the pain of colic 
or otitis, rarely from dentition; at other times it may be simply the 
expression of a condition of extreme nervous irritability, the result of 
inheritance or of the child's surroundings. It is often caused by the 
persistent activities of a fussy nurse or mother. 

In later childhood the first thing to be suspected when sleep is much 
disturbed is some derangement of the digestive organs; in this will be 
found the explanation of fully half the cases. The most frequent type, 
when the symptom is of long duration, is chronic intestinal indigestion, 
often associated with distention, a condition in which formerly the 
usual diagnosis was intestinal worms. Other cases are due to obstructed 
respiration from adenoid growths of the pharynx or enlarged tonsils, 
sometimes to nocturnal attacks of asthma. A lack of fresh air in the 
sleeping room, excessive or insufficient bedclothing, and cold feet, are 
other frequent causes. Disturbed sleep with "starting pains" is one of 
the earliest symptoms of hip-joint disease. In the nervous exhaustion 
resulting from overpressure in schools, and in malnutrition and anemia, 
disturbances of sleep are well-nigh constant. They are also seen in 
organic cardiac disease and in all pulmonary conditions accompanied by 
dyspnea or cough. Sleep may be disturbed in consequence of bad dreams 
which have their origin in exciting stories heard or read just before 
bedtime, or in too violent or exciting play. To discover the cause in 
almost any case it is necessary to investigate carefully the whole routine 
of the child's life. 

Symptoms. — The condition may be one of real insomnia which may 
last for weeks or months ; or the sleep may be simply disturbed and rest- 
less, the child waking many times during the night, and when asleep 
will not lie quietly, but constantly changes his position. Sometimes 
children wake suddenly with a scream, but immediately drop off to sleep 
again. 

Treatment. — The essential treatment consists in the discovery and 
removal of the cause of the disturbance. This will often involve a radical 
change in the manner of feeding* in the hygiene of the nursery, and in 
all the surroundings of the child. A change of nurses sometimes results 



DISORDERS OF SLEEP 713 

in a speedy cure. In no circumstances should the physician counte- 
nance the use of drugs to promote sleep in children, except in the case 
of severe acute disease. Soothing syrups and all nostrums for "teeth- 
ing" should be absolutely forbidden; also the sucking of "pacifiers." 
Many mothers and nurses fall into the habit of using them, because the 
injurious effects are not appreciated. When the cause of sleeplessness is 
found and removed the child will sleep, but compulsory sleep obtained 
under other conditions is usually productive of more harm than good. 
If food, diet, and all bad habits have been corrected, nervous causes 
should be investigated. When no cause can be discovered the treatment 
should consist in putting the child upon the simplest possible diet, and 
in attention to such general conditions as anemia, malnutrition, and 
neurasthenia, some of which are almost certain to be present. In many 
cases a warm bath at bedtime will be found beneficial. A quiet, darkened 
room, plenty of fresh air, and the stopping of both eating and drinking 
during the night, are essential to a cure in most cases. When the con- 
dition accompanies some acute disease, the drugs which are most useful 
are codein and trional. A child of two years may take gr. 2V of codein 
or two grains of trional as an initial dose, to be increased if necessary. 

Night Terrors — Pavor Nocturnus. — Two classes of cases have been 
grouped under this head, both having this in common, that sleep is dis- 
turbed by fright. 

The condition in the first group partakes of the nature of nightmare. 
It may be due to partial asphyxia from adenoid growths of the pharynx, 
or to other causes mentioned under disturbed sleep, or it may be gastric 
or intestinal in its origin. These cases are quite frequent. Sleep may 
be disturbed from the outset, and the attack may be merely the culmina- 
tion of such disturbance. The child wakes in a state of fright and ex- 
citement, and often says he has had a bad dream. His mind is clear, he 
recognizes those about him, but it may be a long time before he is suffi- 
ciently calm to sleep again. The attack may be remembered perfectly 
the next day. Cases like this are to be managed in the same general way 
as those of disturbed sleep above mentioned. 

In the second group are the only cases to which the term "night ter- 
rors" should really be applied. These are relatively rare, but the condi- 
tion is a much more serious one. The symptom is generally due to some 
disturbance of the central nervous system. It occurs especially in those 
of neurotic antecedents, or those who have previously suffered from 
infantile convulsions, and it is often the precursor of other nervous at- 
tacks — migraine, hysteria, epilepsy, and even insanity. The attack usu- 
ally comes suddenly where a child has previously been sleeping quietly, 
and more frequently in the early part of the night than later. He is 
generally found sitting upright in his bed in a bewilderment of terror, 



714 DISEASES OF THE NERVOUS SYSTEM 

being "afraid of the dog/' or "the bear/' or there is some other vision 
or hallucination which has produced the fright. Often this is associated 
with something of a red color. The child does not recognize those 
about him, does not know where he is, and may go to sleep again with- 
out coming to full consciousness. The next day there is no recollection 
of what has happened. Usually no after-effects are seen, but sometimes 
a large amount of pale urine is passed. The attacks may be repeated 
at intervals of a few months, or they may occur every few nights ; but 
whatever the peculiar nature of the vision, it is likely to be repeated in 
nearly the same form. Such attacks have something in common with 
epileptic seizures, and the diagnosis between them may at times be dif- 
ficult. They are to be regarded seriously, not only on account of what 
they are in themselves, but on account of what may follow. 

Treatment. — All mental and nervous strain should be most carefully 
avoided, and when the attacks are frequent the bromids should be given 
at bedtime. Some person should sleep in the same room with the child, 
or in an adjoining one with the door open. 

Excessive Sleep. — It is rare that either infants or children sleep an 
unnatural amount of the time unless one of two causes is present — or- 
ganic brain disease, most frequently tuberculous meningitis, or the use 
of drugs. The latter is always to be suspected if with the sleep there is 
associated obstinate constipation. Opium in the form of "soothing 
syrup" or paregoric is the drug which has usually been given. 



INJURIOUS HABITS OF INFANCY AND CHILDHOOD 

On account of the close connection of such habits with disturbances 
of the nervous system, they may be properly considered with the func- 
tional nervous diseases. Although some of these habits may not be of 
serious importance, yet as a group they usually receive too little atten- 
tion at the hands of the physician. The list is very long, and only the 
most important ones will be discussed. 

Sucking. — This is a very common habit in infants, and during the 
first few months it is seen to some degree in most of them. If they are 
carefully watched the habit is easily stopped ; otherwise it may continue 
indefinitely. Young infants usually suck the fingers when hungry, and 
this can scarcely be considered abnormal, but an effort should always be 
made to stop it, lest the habit become fixed. Lindner distinguishes be- 
tween simple sucking and sucking with combinations. In the former, 
the child sucks some part of the body, such as the thumb, fingers, toes, 
tongue, lips, back of the hand or arm, or it may be some foreign sub- 
stance, such as part of the clothing, the blanket, a rubber nipple, or the 



INJURIOUS HABITS OF IXFAXCY AND CHILDHOOD 715 



"pacifier." This is the most common form that is seen. In the second 
variety the sucking is accompanied by the nibbing- of some other parts, 
which seems to afford a pleasurable excitement; this may be the ear, the 
genital organs, or any other portion of the body. Sometimes sucking is 
accompanied by some practice which produces actual pain, such as pulling 
of the hair or scratching the body. Habits of sucking often persist 
throughout infancy, and not infrequently throughout childhood; they 
have often been known to continue up to puberty. The longer the habit 
has lasted the more difficult is it to break. 

The results of sucking may be serious. Deformities of the thumb or 
finger, of the lips and teeth, and even of the jaws, are sometimes pro- 
duced. We knew a woman whose thumbs to advanced age showed a de- 
formity resulting from the habit of thumb-sucking while a child. In 
her case the habit was not broken until she was eight or nine years old. 
Probably the most pernicious result of sucking is its tendency to develop 
the habit of masturbation. Habitual sucking of one hand or finger may 
lead to spinal curvature. 

Treatment. — In the management of these cases the most important 
thing is to arrest the habit early, before it becomes fixed. Too often the 
habit of thumb-sucking, or of sucking a rubber nipple, is encouraged by 
mothers, nurses, and sometimes even by physicians because of the tem- 
porary quiet which is thereby produced. In no circumstances should 
it be resorted to as a means of putting children to sleep or otherwise 
quieting the nervous system. With infants, the only treatment which 
is at all successful is mechanical restraint. It is of no use to cover the 
part which is sucked with bitter solutions. The hands of young infants 
may be covered with mittens, or with the long sleeves of a night-gown 
which is pinned to the bed, so that it is impossible for the child to get 
the part to the mouth ; or. still better, cuffs or splints of pasteboard may 
be applied at the elbow, so as to prevent flexion of the arms. In the 
milder cases the habit is often discontinued spontaneously; but when 
it has been indulged in until a child is four or five years old, it is broken 
only with the greatest difficulty. Punishments are of little avail, but 
rewards are often successful. 

Masturbation. — This is not uncommon even in infancy. Many cases 
have been observed during the first year, and some as early as the sev- 
enth or eighth month. II is seen in children of all ages and in both 
sexes; but in infants and very young children it is, in our experience, 
much more common in girls than in boys. 

Etiology. — Local causes are preseni in many eases; they are usually 
something which produces undue irritation. The most frequent are, 
long or adherent prepuce, phimosis, balanitis, vulvovaginitis, eczema 
of the labia, threadworms, and tight clothing. A urine which is 



716 DISEASES OF THE NERVOUS SYSTEM 

irritating because of excessive acidity or the presence of crystals of uric 
acid may be a cause. Any irritation may lead the child to rub the parts 
in some way, and a pleasurable sensation being excited, this action is 
'repeated until a habit is formed. Other causes are exercises in which 
the legs are rubbed together, or the body against a pole, as in climbing. 
To these causes must be added, in infants at least, the habit of sucking. 
After infancy the habit of masturbation is usually acquired from other 
children, but sometimes taught by vicious nurses. 

General causes are also important as predisposing factors. These 
are the same as underlie most of the neuroses of childhood — viz., anemia, 
general malnutrition, and a highly neurotic constitution or nervous in- 
stability, which is often an inheritance, and is always aggravated by sur- 
roundings which tend to unnatural stimulation of the nervous system. 
When masturbation develops in a young child without any local cause, 
it may be an early sign of either mental deficiency or moral delinquency ; 
if looked for, other stigmata of degeneration will often be found, and 
in many cases other vicious traits will appear later. 

Symptoms. — In infants and very young children masturbation is 
usually accomplished by thigh friction or by rubbing the body against a 
pillow, a chair, or some other object. The variety of ways is almost end- 
less. Frequently the child will simply lie upon the floor with the thighs 
crossed and rigidly held, and sway the body backward and forward. This 
lasts for a few moments, is accompanied by flushing of the face and 
some appearance of excitement, followed by relaxation, and often by 
perspiration. It frequently happens with little children that these 
"queer tricks," as they are often regarded, have been continued for 
months before their true nature is suspected. 

A consciousness that they are doing something wrong, early leads 
even young children to seek seclusion when they repeat the habit. It 
is especially likely to be practiced when children lie long awake alone 
after they go to bed, or if they wake early. The habit is always 
made worse by any deterioration of the general health. We have known 
many children, who were thought to be entirely cured, to relapse under 
such conditions. 

It is somewhat difficult to separate the general symptoms with which 
masturbation is associated, and upon which it largely depends, from 
those which are the direct result of the habit. There are some children 
in whom the condition is chiefly or entirely dependent upon a local cause, 
or when it is only occasionally practiced, in whom no general symptoms 
are seen, or at most only an unnatural shyness and a disposition to seek 
seclusion. Others are precocious and excitable, with an excessive amount 
of nervous sensibility. There are others in whom more marked nervous 
symptoms are present; the most striking are absent-mindedness, loss of 



INJURIOUS HABITS OF INFANCY AND CHILDHOOD 717 

power of concentration, loss of interest in all amusements, and mental 
depression. Some girls of only seven or eight years may have fairly 
regular periods in which masturbation is practiced. In one of our pa- 
tients such periods for a considerable time occurred monthly. During 
them even very little girls may lose all sense of modesty or decency. 
Every particle of self-control is gone. They become passionate, excitable, 
apparently possessed by the one uncontrollable desire to practice the 
habit. In the intervals such children may be quiet, modest, sweet-tem- 
pered, and perfectly normal. In some older subjects nymphomania, or 
even insanity, may be the ultimate result. Epilepsy, chorea, or hysteria 
may develop, particularly where a strong predisposition to them already 
exists in the family. The effect of masturbation upon the physical and 
mental development of the child may be serious when it is begun at an 
early age or is frequently practiced. But more striking is the change 
sometimes brought about in a child's moral nature. Even little chil- 
dren of eight or nine years may become centers of moral infection, 
which may involve a group of playmates or even a whole school. 

Local symptoms of masturbation are not always present; in the male 
I here may be redness and slight swelling of the prepuce ; the organs may 
be abnormally large or simply much relaxed. The frequent occurrence 
of erections in young boys is always a suspicious symptom. In the 
female there is sometimes seen an abnormal development of the genital 
organs for the age, with an early appearance of pubic hair. Little im- 
portance is to be attached to adhesions of the clitoris. Sometimes there 
is vaginitis. 

Prognosis. — Masturbation in children is at all times a most difficult 
condition to deal with. The outlook is better in infants and young chil- 
dren than in those who are older, because the latter are more difficult to 
watch and control; besides, in them the habit has usually become more 
firmly fixed. In young children local causes are frequently found to be 
at the root of the trouble; in those who are older general causes are 
more often present, and these it may be impossible to remove. In almost 
any case in which the habit has become firmly developed, many months 
and usually several years are necessary for complete cure. The tendency 
to relapse is very strong. When masturbation is a symptom of degener- 
acy it is usually hopeless. 

Treatment. — The most important thing is an early recognition of 
the condition. The physician should put parents and nurses on their 
guard, and the first suspicions should be reported and the child care- 
fully watched until all doubt is removed. In young infants much may 
be accomplished by mechanical restraint. The kind of restraint which 
is necessary will depend upon the manner of masturbating. If by the 
hands, they should be tied during sleep, so that the child can not reach 



718 DISEASES OF THE NERVOUS SYSTEM 

the genitals; if by the thigh-friction, the thighs should be separated by 
tying one to either side of the crib. In inveterate cases, a double side- 
splint, such as is used in fracture of the femur, may be applied. In 
children that are over three years old, all such contrivances are almost 
invariably unsuccessful. It is of the utmost importance in every case to 
have the child under the close surveillance of a competent and trust- 
worthy person. He should be especially watched just after being put 
to bed and immediately after waking. Corporal punishment is often 
useful in very young children, but of little or no benefit in those who are 
over three years old. In fact, in such cases it may do positive harm, for 
deception and lying are soon added to the previous vice. The mother 
should secure the child's confidence, and in every way possible seek to 
strengthen his will and stimulate his self-control, using her influence to 
help him break the habit. In fact, in older children this psychic treat- 
ment is much more important than all other measures. Often absence 
from home under the care of a trustworthy companion is essential to suc- 
cessful treatment. Local causes, too, must be sought and removed when- 
ever found. Circumcision should be done if phimosis exists; and even 
when it does not, the moral effect of the operation is sometimes of very 
great benefit. In girls improvement sometimes follows a separation 
under anesthesia of the preputial hood from the clitoris. But unless 
this is frequently repeated, the adhesions soon recur. Complete circum- 
cision is sometimes done with advantage, and in very obstinate cases 
the clitoris may be cauterized. Blistering the inside of the thighs, the 
vulva, or the prepuce is sometimes useful. But as a rule none of these 
measures accomplishes anything permanent. Care should be taken that 
the clothing does not irritate the parts. The child should be removed 
from all vicious companions ; but it is quite as important that the great- 
est vigilance should be exercised in the home and at school, so that 
the child should have no opportunity to teach other children the habit. 
In the most serious cases the child should be sent away from home and 
kept from other children. The cooperation of a trustworthy nurse or 
companion is indispensable. 

General treatment should be directed to the child's condition; it is 
required in most of the cases. A child suffering from malnutrition and 
anemia should be sent to the country, kept out of doors and away from 
books, studies, and from everything which stimulates or excites the nerv- 
ous system. Almost all active exercises except horseback may be recom- 
mended. Every means should be employed to build up the general 
health. These cases are most difficult and most discouraging ones for 
the physician. A cure results only by using all these measures and for 
a long time. 

Nail-biting and tongue-sucking are two forms of habit which are less 



MALFORMATIONS 719 

frequent and less important than those already mentioned. The former 
is best remedied by wearing gloves and by keeping the nails cut very 
short. Tongue-siicking seldom becomes a fixed habit, and the child usu- 
allv ceases it of his own accord as he grows older. 

Pica or perverted appetite is an inordinate desire to eat various sub- 
stances, such as dirt, sand, mortar, coal, or hair. It is most frequently 
seen in infants but may occur in older children. This habit is met with 
in those who are mentally defective, but not rarely in other children. 
These patients are usually highly neurotic and exhibit some of the other 
habits common to this class. In some children gastric derangements 
seem to play the part of an exciting cause. Pica is a common symptom 
of infection with hook-worm. The habit may continue for years unless 
corrected. The general health often becomes seriously undermined as 
a consequence of the disturbed digestion resulting from the presence 
of abnormal substances in the stomach. Children in whom such a habit 
is present should in the first place be watched and prevented from in- 
dulging in their abnormal craving. Secondly, the digestion and general 
health should be improved according to indications afforded by the 
individual case. 

Head-banging is an expression of extreme nervous irritability most 
frequently seen in infants or in very young children. It is not indicative 
of any special form of nervous derangement, but is caused by the same 
morbid impulse which leads other nervous children to scratch their faces, 
pull their hair, etc. While in some children head-banging occurs only 
occasionally, we have seen patients in whom it existed for a long time. 
It may be repeated almost every night, and continue at intervals for two 
or three hours, and that without temper or excitement, but with such 
force as to produce contusions of the scalp and necessitate padding the 
sides of the crib. It is rarely a symptom of organic brain disease. 
Rickets is often associated and the nutrition of most of the patients is 
much below the normal. The treatment is general. 



CHAPTER III 

DISEASES OF THE BRAIN AND MENINGES 
MALFORMATIONS 

The malformations of the brain arc of great variety, and many of 
them are solely of anatomical interest, as the conditions are incompatible 
with life. Only the most, frequenl and the best-known types will be men- 
tioned, and those which arc of interest from a clinical point of view. 



720 



DISEASES OF THE NERVOUS SYSTEM 



Meningocele, Encephalocele, and Hydrencephalocele. — These three 
conditions have in common a protrusion of some part of the cranial con- 
tents through an opening in the skull. In Meningocele (Figs. 87, 90) 
there is protrusion of the membranes alone. These form a sac, which 




Fig. 87. — Meningocele. 



Fig. 88. — Encephalocele. 



Fig. 89. — Hydrenceph- 
alocele. 



is usually, but not invariably, distended by fluid. In encephalocele (Fig. 

88) there is a protrusion of a portion of the brain substance; this is 
connected with the rest of the brain by a constricted neck or pedicle. 
The tumor may or may not contain fluid. In hydrencephalocele (Fig. 

89) there is a protrusion of a portion of the brain substance which 

contains within it a cavity filled 
with fluid, this cavity communicat- 
ing with the distended lateral ven- 
tricles. 

In all these conditions there is a 
tumor, usually pedunculated, of a 
round or pyriform shape, with a 
smooth or lobulated surface. The 
ordinary size is that of a mandarin 
orange ; it may be as small as a wal- 
nut, or as large as the patient's 
head. It is generally covered by the 
scalp, which is often denuded of 
hair; but it may be covered only by 
granulation-tissue, or it may show a 
central cicatrix, like that of spina 
bifida. Other deformities, such as 
spina bifida, club-foot, and hare-lip are frequently present. 

All these conditions are rare, but the most frequent and most serious 
one is hydrencephalocele, this being usually associated with hydroceph- 
alus. The next in frequency is encephalocele, which has the best prog- 
nosis. This is frequently termed hernia cerebri. If fluid is present, it 
is external to the brain. In meningocele there is simply an accumula- 




Fig. 90. — Meningocele. 
Month old. 



Infant one 



MALFORMATIONS 



721 




Fig. 91. — Frontal 

Meningocele. 

Infant Three Months 

Old. 



tion of fluid, which communicates by a small opening with the general 
arachnoid cavity of the brain. 

Of 105 cases collected by Schatz, 59 occupied the occipital region 
and 46 were frontal. The aperture through which the occipital pro- 
trusion takes place is usually in the median line. It may communicate 
with the posterior fontanel, with the foramen mag- 
num, or with the cleft of a spina bifida. The occip- 
ital bone may be divided in the median line, or rarely' 
it may be absent. 

In the nasofrontal form (Fig. 92) the tumor is 
usually at the root of the nose, a little to one side of 
the median line. The aperture is most frequently 
between the cribriform plate of the ethmoid and the 
frontal bones. It may be between the lateral halves 
of the frontal bone, causing a median tumor. The 
point of protrusion may also be the lateral region of 
the skull, generally about the lateral fontanel, or 
along the line of the sutures; it may project into the 
mouth or the pharynx. These anterior tumors are usually small, al- 
though large ones containing the anterior lobes of the brain have been 
seen. 

The theory of the origin of these malformations which is most widely 
accepted is that they are primarily cases of intra-uterine hydrocephalus, 
and as the cranial cavity is gradually closed by the development of the 
bones, a certain portion of the brain is left outside. 

Symptoms. — The tumor is always congen- 
ital, although after birth it frequently increases 
very much in size. A typical tumor is round 
and elastic, usually giving evidence of fluid; it 
usually pulsates synchronously with the heart; 
during screaming or forced inspiration, it in- 
creases in size; partial and in some cases com- 
plete reduction is possible, but this is usually 
followed by marked cerebral symptoms, even by 
convulsions. After partial reduction, an open- 
ing in the skull may often be made out. Micro- 
cephalus may be present, or there may be unequal development of the 
two sides of the head. 

The following differential points indicate the most characteristic 
features of the three varieties: In meningocele, the tumor is at first 
small, hut increases; if has a smooth surface; M is pedunculated; there 
is distinct fluctuation, perfect translucency, rarely pulsation; often it 
is completely reducible; compression of (he tumor causes cerebral symp- 




Fig. 92. — Nasofrontal 
Meningocele. Infant 
one week old. 



722 DISEASES OF THE NERVOUS SYSTEM 

toms; the skull is normal. In encephalocele, the tumor is small and 
smooth ; it is rarely pedunculated ; fluctuation is absent ; it is not trans- 
lucent; there is distinct pulsation; it is usually reducible; pressure 
causes cerebral symptoms; the skull is normal. In hydrencephalocele, 
there is a large pendulous tumor with an irregular or lobulated sur- 
face; it is pedunculated; translucency is rarely complete; fluctuation is 
distinct; it is irreducible; pressure rarely causes symptoms; microcepha- 
lus and other deformities are often associated. 

The occipital tumors are usually more serious than the frontal ones. 
The majority of cases die in the course of the first few weeks of life, 
death resulting from meningitis, convulsions, or rupture. In menin- 
gocele the tumor usually grows slowly, and ultimately may be shut off 
from the cranial cavity ; but gradual thinning of the membrane may take 
place, and spontaneous or accidental rupture occur. In encephalocele 
the tumor grows slightly, or not at all. Most of these patients ex- 
hibit signs of mental impairment or other evidences of organic brain 
disease. 

Treatment. — According to Treves, operation is justifiable only in 
case of impending rupture. The conditions present are essentially the 
same as in spina bifida. Meningocele may be aspirated or the sac may 
be laid open and a plastic operation performed for the closure of the 
communication with the cranial cavity; or the skin may be divided, and 
a ligature or clamp applied to shut off the communication with the 
brain. All these methods have been at times successful, but recovery 
in many instances is followed by the development of hydrocephalus. 
Encephalocele is to be treated by protection and compression. Aspiration 
may be resorted to if fluid is present. In hydrencephalocele the prog- 
nosis is absolutely bad under all circumstances. Schatz gives the fol- 
lowing statistics, showing the results with and without operation, all 
varieties being included : Of twenty-four occipital tumors not operated 
on, three recovered; of thirty-five operated on by excision, ligation, or 
injection, six recovered. Of forty-six frontal tumors, there were six 
recoveries in thirty-two cases without operation, and two recoveries in 
fourteen cases with operation. 

Microeephalus. — This is often regarded as due to premature ossifi- 
cation of the skull ; but the hypothesis is certainly inadequate to explain 
most, if any, of the cases. In many children suffering from marasmus, 
the sutures ossify and the fontanels close much earlier than in healthy 
infants of the same age, chiefly because, with the rest of the body, the 
brain also has almost ceased to grow. In microeephalus the early ossifica- 
tion of the skull is usually due to arrested growth of the brain, and not 
the reverse. The reasons for the developmental arrest in the brain 
are for the most part unknown. 



PACHYMENINGITIS 723 

It is well known that there is not an invariable relation between the 
size of the head and the size of the brain, although generally the two 
correspond. If the circumference of the head is much below the average 
for the age (see introductory chapters), and relatively much less than 
the measurements of the rest of the body, microcephalia may be assumed 
to exist. Sachs calls attention to the fact that the circumference of the 
head may be nearly normal and yet the essential conditions of micro- 
cephalus exist, owing to imperfect development of the anterior part of 
the brain. 

The symptoms of microcephalus are those of mental deficiency and 
cerebral paralysis, existing in all possible combinations and with variable 
degrees of severity. 

The essential condition in microcephalus being an arrest in the devel- 
opment of the brain, it is not difficult to understand why the operation 
of craniectomy once thought promising has been generally abandoned. 
The results do not justify any operative measures yet proposed for the 
relief of these cases. 

Congenital Hydrocephalus. — These cases may fairly be considered as 
belonging in this group, although they are discussed elsewhere. 

Porencephaly (literally, a hole in the brain) is a condition in which 
there is a large depression in some part of the brain, but with surround- 
ing parts well developed. Such depressions may involve a whole lobe, 
and they may be deep enough to reach the lateral ventricles. 

Porencephalia is described as congenital or acquired. In the con- 
genital form, the defect is usually found in the anterior or middle part 
of the brain. The origin of these conditions is still a disputed question. 
They are probably due to early vascular changes. Children sometimes 
live several years with very large defects, the symptoms depending upon 
the seat of the lesion. The acquired form of porencephalus is usually 
one of the late results of meningeal hemorrhage. It may affect one or 
both sides. Such cases present the symptoms of spastic paralysis — 
usually diplegia. In all cases with large brain defects, the space is filled 
with fluid. 

PACHYMENINGITIS 

Pachymeningitis, or inflammation of the dura mater, occurs both as 
an acute and a chronic disease. 

Acute Pachymeningitis. — Tins i< very rare in children. Only pachy- 
meningitis externa is generally included under this term, as acute pachy- 
meningitis interna does not occur alone, but usually with inflammation 
of the pia mater (leptomeningitis). It may he associated with dig 
or injury of the bones of the skull, but is most frequently seen in con- 



724 DISEASES OF THE NERVOUS SYSTEM 

nection with middle-ear disease. It generally begins as a localized proc- 
ess, but the inflammation may extend to the inner layer of the dura, 
and to the pia mater; or it may remain circumscribed, and termi- 
nate in the formation of an abscess between the dura mater and the 
bone. 

The symptoms of acute pachymeningitis are distinctive only when 
the process is localized. They are then usually associated with middle- 
ear disease, and are indistinguishable from those of cerebral abscess. 
The treatment is surgical. 

Chronic Pachymeningitis. — This, in children, almost invariably af- 
fects the inner layer of the dura mater (pachymeningitis interna) ; it is 
also known as pseudo-membranous and as hemorrhagic pachymeningitis 
or hematoma of the dura mater. Its causes are for the most part un- 
known. It is a rather rare condition, being usually discovered at 
autopsy in children, chiefly cachectic infants, who have died of other 
diseases. 

Two classes of cases are to be distinguished — those with, and those 
without extensive hemorrhages. In the latter group there is found a 
thin, translucent, vascular membrane lining the inner surface of the 
dura. It may be only a delicate film which can be scraped off ; it may be 
as thick as ordinary blotting-paper, or even twice that thickness. The 
membrane is often edematous; it is exceedingly vascular, and the vessels 
have very thin w r alls. There are usually scattered punctate hemor- 
rhages, and there may be a few of larger size. This membrane may cover 
the whole inner surface of the dura, but in most cases it is principally 
over the convexity and may be found only here; it is apt to be more 
upon one side than upon the other. In cases of long standing there may 
be adhesions between the dura and the pia. When large hemorrhages 
have taken place, quite a different pathological appearance is presented. 
The lesions found in one of our cases are fairly typical : The infant was 
six months old, and the symptoms had existed for six days. The fontanel 
was bulging to a marked degree, and the sagittal and coronal sutures 
were separated. A thin recent clot from one-eighth to one-fourth of 
an inch in thickness covered nearly the whole of the right hemisphere 
and part of the convexity of the left. The entire dura was lined both 
at its convexity and base by a pseudo-membrane of grayish color, about 
one-sixteenth of an inch in thickness. The brain was anemic. 

In cases of longer standing partial organization of the clot may be 
seen; in more recent ones the blood is partly or entirely fluid. We once 
saw acute leptomeningitis with a purulent exudation, associated with 
hemorrhagic pachymeningitis. In cases where life is prolonged for 
years, there may be partial or even complete absorption of the clot, fol- 
lowed by the formation of cysts, considerable inflammatory thickening 



PACHYMENINGITIS 725 

of the pia with deposits of blood pigment, and finally atrophy and 
sclerosis of the cortex. The source of the hemorrhage may be the rup- 
ture of a single large vessel, but more frequently the blood comes from 
many small vessels. 

Symptoms. — These are due to the hemorrhage, and not to the inflam- 
matory process. Until hemorrhage occurs there are no symptoms by 
which the disease can be recognized. Thus in many of the cases in which 
pachymeningitis is found at autopsy, its existence is not suspected dur- 
ing life. The occurrence of hemorrhage is sometimes marked by vomit- 
ing or convulsions, and usually there is loss of consciousness. It may 
be a question whether the convulsions are the cause or the result of 
the hemorrhage. In most cases they seem to be the result. They are 
usually general and repeated. If the hemorrhage occurs slowly, there 
may be stupor without convulsions until nearly the end. In the fatal 
cases the symptoms generally continue from two days to a week. There 
are dulness, stupor, and finally coma, death occurring in coma or con- 
vulsions. If the hemorrhage is diffuse — and this is apt to be the 
case — there is rigidity of all the extremities; if it is of one side only, 
the rigidity affects only one arm and leg. The pupils are more fre- 
quently contracted, but may be dilated or unequal. There is diplegia, 
hemiplegia, or monoplegia, according to the seat and extent of the 
hemorrhage. The respiration is slow and irregular and may be of the 
Cheyne- Stokes variety. The pulse is slow, irregular, and sometimes 
intermittent. The temperature is at first normal, but rises slowly until 
death occurs, when it is from 100° to 103° F. Generally the cranial 
nerves are not affected, and opisthotonus is absent. The knee-jerk is 
often exaggerated. In cases which do not prove fatal — these being chiefly 
in older children — we have a similar onset, but after a few days con- 
sciousness is regained, and only hemiplegia or monoplegia remains. 
The course of the paralysis is that seen after meningeal hemorrhage 
due to other causes. Wagner has reported a case in which recurring 
hemorrhages took place at intervals of several months, the autopsy 
showing distinct evidences of both old and recent lesions. 

Pachymeningitis, we are inclined to believe, plays a more important 
role in the production of meningeal hemorrhages in children than has 
generally been accorded to it. From the frequency with which litis lesion 
is found as a cause of sudden meningeal hemorrhages which are fatal, it 
is not unlikely that some of the cases which recover with hemiplegia or 
monoplegia, may be due to the same cause. 

The prognosis depends upon the age of the patient and the extent of 
the hemorrhage. Extensive hemorrhages are usually fatal in infancy, 
but small ones are seldom so. for they are rarely at the base. The prog- 
nosis of the paralysis in cases not terminating fatally is the same as 



726 DISEASES OF THE NERVOUS SYSTEM 

after meningeal hemorrhage due to oilier causes, with perhaps an added 
liability to recurrent attacks. 

Without large hemorrhages, pachymeningitis interna can not be 
diagnosticated; and it is impossible to differentiate the hemorrhagic 
cases from other varieties of meningeal hemorrhage. It is important to 
make a diagnosis between pachymeningitis with hemorrhage, and acute 
meningitis. In the former there is a sudden onset; stupor occur- 
ring early, usually on the first day, gradually diminishing in cases of 
recovery, or deepening into coma in fatal cases; localized or general 
paralysis, also occurring early; there is no fever in the beginning, and 
only moderate fever at the close. In acute meningitis there is usually 
a higher temperature, especially early in the disease; coma develops 
later, and rigidity of the extremities is less pronounced. However, when 
the hemorrhage occurs in the course of some other disease, a differential 
diagnosis may be impossible without lumbar puncture. 

Treatment. — The treatment of hemorrhagic pachymeningitis is 
symptomatic. The indications are, to relieve cerebral congestion by ap- 
plying ice to the head, to allay irritative symptoms by the use of bromids, 
and to keep the patient perfectly quiet. 



ACUTE MENINGITIS 

Several different varieties of acute meningitis are met with in chil- 
dren. Cerebrospinal meningitis is the only form which occurs epidem- 
ically ; but this is also seen as a sporadic disease. It is due to a specific 
organism, the meningococcus. There are several other forms of acute 
meningitis which more or less closely resemble cerebrospinal meningitis 
clinically, and which were for a long time confounded with it. Pneu- 
mococcus and influenza meningitis are usually secondary inflammations, 
but sometimes are apparently primary. The typhoid bacillus and the 
gonococcus may cause acute meningitis, but very rarely in children. 
Acute meningitis may be due to any of the pyogenic organisms. This 
is sometimes spoken of as "septic" meningitis, and is almost invariably 
secondary. Finally, there is tuberculous meningitis, altogether the most 
common variety in young children except during epidemics of cerebro- 
spinal meningitis. 

Some idea of the relative frequency of the different forms of acute 
meningitis as seen apart from epidemics, may be gained from the fol- 
lowing figures which give the number of cases occurring in the Babies' 
Hospital for a series of years, the diagnosis in every case being made by 
lumbar puncture or by autopsy. The patients were nearly all under 
three years of age. The organism found was as follows : 



CEREBROSPINAL MENINGITIS 

Tubercle bacillus 157 cases 

Pneumococcus 23 " 

Meningococcus (sporadic) 24 " 

Staphylococcus or streptococcus 11 " 

Influenza bacillus 5 " 

Colon bacillus . I 



CEREBROSPINAL MENINGITIS 

(Epidemic Meningitis; Cerebrospinal Ferrer) 

Epidemics of cerebrospinal meningitis are separated by quite long 
intervals and occur without any assignable cause. The following chart 
(Fig. 93) represents the prevalence of the disease in New York City 
during forty years. But little was seen of cerebrospinal meningitis until 
the epidemic of 1872. Since that time a certain number of deaths from 
this cause have occurred each year; but there have been seen about once 



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Fig. 9: 



■Chart showing Deaths from Cerebrospinal Meningitis in Nkw York 
City, for Forty Years, per 100, 000 of Population. 



in ten years epidemics of greater or less severity. The most important 
one was that of 1904-5. After each epidemic, for two or three years, 
the disease is prevalent, but it occurs with gradually lessening frequency 
unlil the average incidence is readied. Whal lias been said of New 
York is true of almost every large city. In remote country towns, 
epidemics are occasionally witnessed, and after prevailing a few months 
the disease disappears as mysteriously as il came. Rpidemics are usually 
seen in the winter and early spring, lasting for several months, gen- 
erally reaching their height in March or April and slowly subsiding as 
warm weather approaches. 

With reference to the cause of epidemics very little is known. When 

the disease prevails in cities it occurs especially in crowded tenements, 
being relatively infrequent iii private houses. 



728 DISEASES OF THE NERVOUS SYSTEM 

Cerebrospinal meningitis has only recently been included among 
the communicable diseases. In a series of observations made by the 
New York Health Department the meningococcus was found in the 
nasal secretion of fifty per cent of the cases of meningitis examined 
during the first two weeks of the disease. It was found in the nasal 
mucus in ten per cent of the persons in close contact with cases. In 
Flexner's experiments upon monkeys he found the organism in the nasal 
mucus after animals had been inoculated by way of the spinal canal. 
These observations indicate that the nasal mucosa is a common avenue of 
infection and probably also a channel of elimination. The degree of 
communicability when compared with the common contagious diseases 
seems very slight. In fully seventy per cent of the cases investigated 
in the New York epidemic of 1904-5, but one person in a household was 
affected, although no effort at isolation was made. We have never known 
the disease to originate in a hospital patient, although in New York 
cases of cerebrospinal meningitis have been until recently received into 
the general wards with other patients. Sporadic cases of meningitis 
occur after epidemics, and quite apart from them without apparent 
cause, and it is very exceptional that any connection with a previous 
case can be established. About fifty per cent of the cases of cerebro- 
spinal meningitis occur in children under five years, and about twelve 
per cent in those under one year. The youngest case we have seen was 
in an infant six weeks old. 

The specific organism of cerebrospinal meningitis is the diplococcns 
intracellularis of Weichselbaum or, as it is now generally designated, 
the meningococcus. It is present in the meningeal exudate, in the 
cerebrospinal fluid obtained by lumbar puncture, and in some cases can 
be demonstrated in the blood, the lungs and oilier organs, sometimes 
in the large joints. It is almost invariably found in pairs or tetrads 
within the leucocytes. It is decolorized when stained by Gram's method. 
Outside the body the organism is unknown. 

Lesions. — In epidemic meningitis death may take place so early that 
the changes found at autopsy are slight. There may be only a serous 
exudation and intense hyperemia, which is doubtless much less marked 
after death than during life. The cerebrospinal fluid is turbid and 
much increased in amount. The microscope, however, may show, even 
in these early cases, an abundant exudation of leucocytes in the pia 
mater. After the third day the lesions are quite uniform. The con- 
volutions appear somewhat flattened from pressure due to distention of 
the ventricles. The inner surface of the dura is usually normal or only 
congested. There may be thrombi in any of the cerebral sinuses, or in 
the meningeal veins of the convexity. There is an exudation of greenish- 
yellow fibrin, which is sometimes very abundant. It is generally widely 



CEREBROSPINAL MENINGITIS 729 

distributed, but is usually most marked over the anterior half of the 
brain and at the base. In some cases it is limited to the base, but very 
rarely limited to the convexity. There is an increase in the quantity of 
cerebrospinal fluid. The ventricles are moderately distended with serum 
or sero-pus, and their walls may be slightly softened. The brain sub- 
stance of the cortex may be reddened or may appear normal. In the men- 
inges of the cord, lesions similar to those of the brain are usually seen. 
The exudation is principally upon the posterior surface, and may extend 
throughout the entire length of the cord, or be limited to its upper or 
to its lower portion. 

Microscopical examination shows the exudation to consist of fibrin 
and pus cells, which infiltrate the pia mater. The superficial layers of 
the cortex in the inflamed areas often show minute hemorrhages and 
very marked cell-infiltration. Minute abscesses may be present. Very 
marked degenerative changes can usually be demonstrated in the nerve 
cells themselves. The cells of the neuroglia are also affected ; they are 
swollen and increased in number; and there may be proliferation of the 
connective tissue about the blood vessels. Changes similar to those just 
described may be found in the cord, but these are less frequent and as 
a rule much less severe than those in the brain. Inflammatory products 
are sometimes present in the central canal of the cord and in the walls 
of the lateral ventricles of the brain. The inflammatory process fre- 
quently extends along the cranial nerves, especially the auditory and 
optic, and this may result in otitis or choroiditis; from the cord, it may 
extend along either the anterior or posterior nerve roots. Descending 
degeneration is found in the nerves both of the brain and the cord. 

In patients that die after the disease has lasted two or three months, 
the later results of these lesions may be seen. There is usually present a 
chronic meningoencephalitis, sometimes diffuse, sometimes localized. 
The pia mater is cloudy, thickened, and frequently adherent to the 
brain. Here and there are seen small, yellow, opaque patches which are 
the result of fatty changes in the cells and fibrin of the exudate, with 
some proliferation of connective tissue. The lesions are usually most 
marked at the base, where the thickening of the meninges and the ad- 
hesions may lead to the development of a secondary hydrocephalus. 

In cases which have lasted a much longer time very marked changes 
are found in the brain substance. There may be generalized menin- 
geal adhesions, with a diffuse cortical atrophy, but more frequently there 
are areas of sclerosis, especially over the frontal and temporosphenoidal 
lobes, with which there are almost always associated marked descending 
degenerative changes in the cord. Such Lesions are, of course, perma- 
nent, and Beriously interfere not only with the functions, but also with 
the growth and development of the brain. 



730 DISEASES OF THE BRAIN AND MENINGES 

The lesions and their effects are well illustrated by one of our patients 
who died six months after an attack. She was a bright little girl of 
four and a half years, and had a typical attack of meningitis of moderate 
severity. Convalescence was slow, but at the end of two months recovery 
was perfect in everything but her mental condition. She remembered 
nothing which she had previously learned in the kindergarten, where she 
had been an exceptionally bright pupil. Her mind was a blank. She 
was dull, listless, and her face had a vacant, idiotic expression. The 
special senses seemed unaffected, and her speech was retained. She died 
during an attack of convulsions. At the autopsy the pia was everywhere 
thickened and adherent, while in the cortex were present the earlier 
changes of a general encephalitis. 

The visceral lesions most frequently found in epidemic meningitis 
are pulmonary. There may be lobar or bronchopneumonia, and in the 
lungs may be found the same organism as in the brain. Acute degen- 
eration of the liver and kidneys is also frequent. The other viscera are sel- 
dom affected. Occasionally suppurative inflammation of the joints occurs. 

Symptoms. — The symptoms of cerebrospinal meningitis do not differ 
essentially in the sporadic and epidemic cases, except that the most 
severe forms of the disease are seen in the latter. They may be divided 
into several quite distinct groups: 

1. Hyper-acute Form. — Cases of this kind are rarely seen except in 
an epidemic, and usually occur at its height. The onset is very abrupt, 
the course short and intense, and death may take place in from twelve 
to thirty-six hours. The following case illustrates this type : A little 
girl of ten years was well enough at 2 p.m. to carry a bundle of clothes 
a dozen city blocks. Returning home, she complained of intense head- 
ache, vomited frequently, and was so weak that she was obliged to go to 
bed. In a few hours she passed into deep coma, with very high fever, 
and died at 11 p.m. 

The earliest symptoms are usually intense headache, repeated attacks 
of vomiting, and very high fever. There is great prostration and the 
nervous symptoms increase so rapidly that in a few hours the patient 
may become comatose and death occur in a short period. The tempera- 
ture rises rapidly to 103° or 104°, sometimes to 106° F. A few petechial 
spots may be discovered over the face, chest, or extremities. There is 
usually no rigidity, but rather general relaxation. The pulse is weak, 
in most cases rapid, but sometimes slow and irregular. The respiration 
is usually irregular both in frequency and depth. 

The symptoms appear to be due to two factors : the intensity of the 
infection, and the rapid accumulation of cerebrospinal fluid, causing 
coma with eventual respiratory paralysis. Usually both these factors 
are present, but the second one seems the more important. In support 



CEREBROSPINAL MENINGITIS 



731 



of this view is the striking infrequency of cases of this type In in- 
fants with an open fontanel. Should the patient survive the violence 
of the onset, a period of reaction occurs, and after a day or two the dis- 
ease follows the regular course. 

2. Usual Form. — In this also the onset is generally abrupt, but not 
so violent as in the cases just described. It may be marked by intense 
headache, vomiting, convulsions, delirium, chills, and fever with general 
hyperesthesia and rigidity. The initial temperature is from 101° to 
10-1° F. Opisthotonus, with severe pains in the back of the neck and 
along the spine, and general muscular rigidity are usually present. 
There is often active delirium, but rarely stupor or coma. The pulse 




Eig. 94. — Posture in Cerebrospinal Meningitis. (Smith.) 



is generally rapid. 120 to 150, and sometimes irregular. The respira- 
tion is often slightly irregular, and it may be rapid or slow. The erup- 
tion is not so frequently seen as in the very acute cases. 

As the disease progresses, the nervous symptoms often change but 
little from day to day for two or three weeks. They are mainly of the 
irritative type — moderate delirium, extreme hyperesthesia, tremor and 
muscular rigidity. The posture is quite characteristic (Fig. 94). Ow- 
ing to the opisthotonus the child can not lie upon the back, hut rests 
upon the side, with arched spine ami neck, and general flexion of the 
extremities. There is a rather rapid loss in weight, steadily increasing 
prostration, and a weak, rapid pulse. The bowels are usually constipated. 
From lime to time attacks of vomiting occur. In many case- there is 
considerable difficulty in feeding. The duration of this form of the dis- 
ease without specific treatment is from three to six weeks. The course 
is often marked by periods of remission and exacerbation. If recovery is 



732 DISEASES OF THE NERVOUS SYSTEM 

to take place, the temperature gradually falls to normal and often at 
times it is subnormal. The mind becomes clear, and one by one the 
nervous symptoms disappear, the muscular rigidity being usually the 
last to go. Convalescence is always protracted. 

In cases ending fatally, the patient usually passes into a deep stupor 
or coma, with extreme prostration, a slow, weak, irregular pulse, shallow 
respiration of the Cheyne- Stokes variety, sunken abdomen, general re- 
laxation, and death occurs from exhaustion or from bronchopneumonia. 

Occasionally the attack is much prolonged, the fever and all the 
active symptoms continuing from eight to twelve weeks. Emaciation 
sometimes becomes extreme, and with a few nervous symptoms may con- 
tinue long after the fever ceases. In infants, death is often due to 
marasmus. While a fatal outcome is more frequent in these prolonged 
cases, a few recover completely, even when marked symptoms have lasted 
for eight or ten weeks. 

3. Mild Form. — Especially toward the end of an epidemic, and some- 
times occurring sporadically, there are seen cases which in their onset 
and for the first two or three days resemble those just described; but 
instead of running the usual course, the fever and the nervous symptoms 
subside rapidly and convalescence is established early. 

4. Chronic Form. — Owing sometimes to the extent, sometimes to the 
position of the lesions, the disease does not subside at the usual time, 
but nervous symptoms continue after the temperature and most of the 
other constitutional symptoms have passed away. These cases are chiefly 
of the basilar type, and often lead to the development of chronic basilar 
meningitis with secondary hydrocephalus. They are more fully con- 
sidered in a later chapter. 

Onset. — One of the most striking features of this disease is the ab- 
ruptness with which it develops. Occasionally there are indefinite symp- 
toms for a day or two before active symptoms begin; but in the great 
majority not only the day, but the hour of the onset is definitely marked. 
The most frequent initial symptoms are the simultaneous occurrence of 
severe headache and vomiting, followed by high fever and marked pros- 
tration. The vomiting is usually repeated, projectile, and has no relation 
to meals. Convulsions occurred in the beginning of thirty per cent of 
our cases. Occasionally a decided chill is seen. After twenty-four hours 
acute general pains and hyperesthesia are usually present, together with 
rigidity of the muscles of the neck and extremities, giving rise to opis- 
thotonus and muscular contractions. 

Shin. — Eruptions upon the skin vary much in frequency in different 
cases and in different epidemics. The most characteristic one is the 
appearance of small punctate hemorrhages, resembling flea bites; they 
are not numerous, but may be found on almost any part of the body, 



CEREBROSPINAL MENINGITIS 733 

most frequently upon the extremities, the upper part of the chest, and 
neck. In our experience they have been present in about fourteen per 
cent of the cases. Sometimes larger hemorrhages are present. We have 
twice seen a very extensive purpuric eruption with hemorrhagic areas 
from half an inch to three inches in diameter over the face, buttocks, and 
extremities. This eruption belongs to the early stage of the disease 
and is rarely visible after the third or fourth day unless unusually 
extensive. In some cases a general erythema is present; in others, an 
eruption closely resembling measles. Herpes upon the lips and face is 
common in older children, but is rare in infants. Bed-sores are very 
common in protracted cases. They are found over pressure points — 
the trochanter, the malleoli, and the side of the head ; in several instances 
the ear has been the part affected. 

Nervous System. — Headache is a frequent initial symptom and is 
usually severe ; it is more often frontal than elsewhere, and may be asso- 
ciated with vertigo. There are acute pains in the back of the neck, along 
the spine, and marked general hyperesthesia, which is often so intense 
that any movement of the body causes agonizing cries. This is one of 
the most striking symptoms of the disease, and may continue throughout 
the acute stage. The mental state varies much in different cases. De- 
lirium is frequent in the early stage of the severe form; it is usually 
active, sometimes maniacal. After delirium dulness or apathy ensues, 
giving place to great irritability when the patient is disturbed. Con- 
vulsions are not uncommon early, but are seldom repeated in the course 
of the disease or toward its close. There is rarely continuous stupor or 
deep coma except toward the end of fatal cases. In many cases with high 
temperature and quite severe symptoms, after the subsidence of a short 
early stage of excitement or delirium, the mind remains perfectly clear 
throughout the attack. In these circumstances an erroneous diag- 
nosis is often made, particularly if the physician has not observed the 
case from the beginning. 

Tonic spasm of the various muscular groups is one of the most char- 
acteristic features of this disease and is seldom absent. Like the hyper- 
esthesia it is persistent. The rigidity and contraction of the muscles 
of the neck and back produce cervical or general opisthotonus; cervical 
opisthotonus is most marked with lesions chiefly at the base, and may 
be wanting in the rare cases when the lesion is almost entirely at the 
convexity. Tonic*spasm of the extremities usually causes general flexion 
of the thighs, legs, and arms. Late in the disease this may be replaced 
by complete extension of the lower extremities with dropping of the 
feet. The tonic muscular spasm gives rise to Kernig's sign, viz., inabil- 
ity to extend the leg when the thigh is flexed upon the body. In young- 
children one should not place too much dependence upon this sign. 
25 



734 DISEASES OF THE NERVOUS SYSTEM 

While rarely wanting in cerebrospinal meningitis, it may be present 
in other conditions. Brudzinski's sign is frequently present, but not 
diagnostic. Muscular rigidity is one of the most constant symptoms of 
cerebrospinal meningitis and one of the last to disappear. It may be 
absent in the early stage of the hyper-acute cases, and very late in fatal 
cases, when there may be general relaxation. Other nervous symptoms 
frequently present are ankle clonus, muscular tremor, especially of the 
hands, and paralysis, which may be facial, monoplegic, or hemiplegic. 
Early in the disease the knee-jerks are usually increased ; in the later 
stages they may be lost. 

Eye and Ear. — The pupils in the early stage are generally contracted ; 
toward the close they are usually widely dilated. Ocular paralyses are 
not so frequent or so marked as in tuberculous meningitis. The same 
is true of the changes in the optic disc, although these vary much in 
different epidemics. There may be congestion of the fundus, retinitis, 
or optic neuritis. In some epidemics such changes have been observed 
in fully half the cases. In that of 1904-5, in our hospital cases, they 
were rarely- seen, and then were but slightly marked. Conjunctivitis 
is frequently present and may be severe. There may be choroiditis 
and sometimes complete destruction of the eye, but usually this is uni- 
lateral. In most epidemics the ears are more frequently affected than 
the eyes. Early deafness may be due to a lesion of the auditory nerve, 
is generally bilateral, and often permanent. Acute otitis media occurs 
as a Complication, and the meningococcus is occasionally found in the 
discharge. Permanent deafness is sometimes due to changes in the audi- 
tory nerve or in the brain itself. 

Fever. — This disease is usually attended by high fever, but the curve 
is apt to be an irregular one and show wide variations. The temperature 
is nearly always high at the onset: in the hyper-acute cases it may 
reach 106° F. or higher. The usual range during the disease is from 
100° to 105° F. (Fig. 95). Sometimes it is steadily high; not in- 
frequently a few days after a sharp acute onset it falls nearly or quite 
to normal and remains there for several days. Cases seen in this afebrile 
period are most difficult of diagnosis. This stage may be followed by 
another sharp rise, and afterward continuous fever. Periods of remis- 
sion and exacerbation in the temperature are seen in a large proportion 
of the prolonged cases. Often it becomes subnormal. The temperature 
may bear no relation to the severity of the other symptoms. Its course 
is greatly modified by the serum treatment. 

Respiration is disturbed very early in the disease, when it is often 
irregular and may be slow or rapid. Throughout the greater part of 
the attack it may be nearly normal. Occasionally it is of the typical 
Cheyne-Stokes variety. 



CEREBROSPINAL MENINGITIS 



735 



Pulse. — Throughout the greater part of the disease the pulse is rapid. 
In the early stage it is often weak, and sometimes irregular. The average 
frequency in young children is from 130 to 150. A slow, irregular pulse 
is occasionally seen late in the disease in patients who are in deep coma. 

Blood. — A leucocytosis is present in nearly all cases. The average 
is from 25,000 to 40,000. The increase is chiefly in the polymorpho- 
nuclear cells which usually form from 80 to 85 per cent, of the leu- 
cocytes. Blood cultures made early in the disease have in some cases 
shown the presence of the characteristic organism. 

Digestive System. — Vomiting is one of the most frequent symptoms 
of onset but rarely persists throughout the attack. Late in the disease 




Fig. 95. — Cerebrospinal Meningitis. Recovery without serum treatment. Fairly 
typical chart of prolonged case, showing remissions and exacerbations. Patient 3K 
years old; unconscious, blind, and deaf for 2K months; complete recovery. 



it may be most troublesome. As a rule constipation is present. The 
tongue is coated, dry, glazed, sometimes covered with sordes. In a small 
proportion of cases jaundice has been observed. On account of the loss 
of appetite, great irritability, delirium, and stupor, the greatest difficulty 
is often experienced in feeding these patients. In young children gavage 
is much more satisfactory than rectal feeding. Early in the disease the 
abdomen is natural. In the late stage it is often very much retracted. 

General Nutrition. — This is impaired in nearly all eases. There is a 
progressive wasting, greater than would be explained by the disturbance 
of digestion. In the protracted cases it may he extreme. Infants and 
young children often die of inanition or marasmus long after the active 
symptoms of the disease have subsided. 

Other symptoms of importance are the tense, bulging fontanel, in 



736 DISEASES OF THE NERVOUS SYSTEM 

infants rarely absent early in the attack, but often wanting in the late 
wasting stage; incontinence of urine and feces, and retention of urine, 
are very frequent and often overlooked; occasionally swelling of some 
one of the large joints is seen. 

Course, Duration, and Termination. — Excluding the hyper-acute 
cases in which death occurs very early, the usual duration of active symp- 
toms in cases not treated with serum is from three to six weeks. Of 350 
cases recovering without serum, the disease lasted less than one week in 
three per cent ; in fifty per cent it was five weeks or longer. Some very 
protracted cases terminate favorably. We have seen one child recover 
completely after 84 days of fever, and another after 102 days. Most of 
the prolonged cases are marked by periods of exacerbation and remission. 
Not until the temperature has been normal for several days, the mind 
has become clear, and the hyperesthesia and rigidity have entirely disap- 
peared, can we consider convalescence as established. Eecovery is slow, 
and it may be many months before the child is quite well. In 220 cases 
receiving serum treatment the average duration of active symptoms after 
the first injection was 11 days. 

In fatal cases, death may come early from coma, convulsions, or 
heart failure. It may occur in the middle period from complications, 
most frequently pneumonia, or the terminal stage of the disease may be 
seen with extreme wasting, and finally death from exhaustion. 

Complications and Sequelae. — The chief complications are pneu- 
monia, otitis, conjunctivitis or choroiditis, and bed-sores ; rarely, nephritis 
and arthritis. Sequelae are, unfortunately, very common. There may 
be perfect recovery so far as physical functions are concerned, but the 
child be left mentally deficient. In some cases the defect is so slight 
as not to be evident for several months or even years; in others the 
mental faculties are entirely lost. There may also be various types of 
paralysis — strabismus, facial paralysis, monoplegia, hemiplegia or diple- 
gia, and often contractures, which are sometimes temporary, but apt to 
be permanent. The acute attack may be followed by chronic meningitis 
with hydrocephalus. Deafness is quite common, usually of both ears, 
and deaf -mutism is not an infrequent result in young children. Blind- 
ness is not so common and is usually unilateral. As a late result epilepsy 
may develop. 

Prognosis. — The mortality is usually higher in epidemics than when 
the disease occurs sporadically. It is usually greater at the height of 
an epidemic and lower at its close. The average mortality before the 
serum treatment was about 70 per cent. We know of no recorded epi- 
demic in which the mortality was less than 50 per cent. In the last year 
(1905) of the New York epidemic, of 1,780 cases tabulated by the De- 
partment of Health the mortality was 76 per cent. Of 59 cases treated 



CEREBROSPINAL MENINGITIS 737 

in our hospital wards in the same epidemic the mortality was 80 per 
cent, nearly all these patients being under three years of age. Of 24 
cases under one year only one recovered. Of the cases seen in private 
practice, largely older children, the mortality was 50 per cent. Xone of 
these had serum treatment. Not all of those who do not die are to he 
classed as recoveries, for in fully 25 per cent serious sequelae remain. 
The results with serum are referred to under Treatment. 

Diagnosis. — Lumbar puncture is the only accurate means of diag- 
nosis we possess. By it we can not only differentiate meningitis from 
other diseases with nervous symptoms, but can distinguish this from 
other varieties of meningitis. Furthermore, this is possible very early in 
the disease. With proper precautions it is practically free from danger, 
and it should be employed whenever meningitis is suspected. The 
procedure is not difficult, but the technic is important. 1 The quantity 
of fluid which may be removed at one time varies from a few drops to 
three or four ounces. During the first day or two it is usually slightly 
cloudy; sometimes it is very turbid and it may be thick and purulent. 
As the disease progresses the pus cells gradually diminish, and in favor- 
able cases disappear, but may reappear with an exacerbation of the symp- 
toms. These changes are much modified by serum injections. 

The presence of many leucocytes in the cerebrospinal fluid indicates 
meningitis, which may be due to the meningococcus, but also to the 
pneumococcus, the influenza bacillus, the staphylococcus, or the strepto- 
coccus. The variety can be determined only by microscopical examina- 

1 Puncture should not be attempted with an ordinary surgical exploring 
needle, but with the special lumbar needle devised by Quincke. This is merely 
a fine trocar and cannula and is made stronger than an exploring needle, which 
may break. The child is placed upon the right side with the thighs tightly 
flexed against the abdomen to separate the spines and laminae of the vertebrae 
as much as possible. The point chosen for puncture is in the median line be- 
tween the third and fourth lumbar vertebrae. This is on a level with the high- 
est part of the iliac crest. The strictest asepsis is required. The skin should be 
cleansed and painted with iodin and the needle boiled. The pain is no greater 
than from exploratory punctures elsewhere. No anesthetic is necessary for in- 
fants, but sometimes is required for older and especially sensitive or nervous 
children unless they are comatose. Local anesthesia may be employed or a few 
whiffs of chloroform given, but always with caution, for the combined shock of 
the puncture and the chloroform is sometimes considerable. The child should 
be closely watched for at least fifteen minutes after the puncture is made. The 
canal is reached at the depth of about one inch. The trocar is now withdrawn 
and the fluid usually flows freely through the cannula, sometimes spurting forth 
some distance, owing to high pressure. A dry puncture is generally due to the 
fact that the canal has not been entered; sometimes, because the exudate is too 
thick to flow through the small needle, or the needle may be plugged. Raising 
the patient to a sitting posture usually causes a freer flow, as docs also flexing 
the head upon the chest if opisthotonus is extreme. 



738 DISEASES OF THE NERVOUS SYSTEM 

tion of stained smears from the sediment of the fluid obtained after 
standing or after centrifuging, and by cultures, which should be made 
immediately after the fluid is withdrawn. In cerebrospinal meningitis 
diplococci are found within the pus cells and some are also free in the 
fluid. The organisms are usually numerous. 

The diagnostic value of lumbar puncture, when properly performed, 
is very great ; not only are positive findings conclusive, but early negative 
findings almost certainly exclude meningitis. Exceptional cases are oc- 
casionally met with in which early punctures give a clear fluid and no or- 
ganisms are found; a few days later the fluid becomes turbid and organ- 
isms are abundant. The meningococcus may persist for a long time. In 
one of our cases not treated by serum it was present on the ninetieth day. 

The diagnosis of cerebrospinal meningitis by symptoms alone presents 
peculiar difficulties at the beginning of the attack. The most valuable 
early symptoms for diagnosis are, a sudden onset with intense headache, 
vomiting, high temperature, prostration, the petechial eruption, marked 
rigidity of the neck and extremities, with hyperesthesia, great irritability 
or early stupor. Later, three symptoms are rarely wanting — per- 
sistent hyperesthesia, muscular rigidity of the neck and extremities, 
and fever. Kernig's sign is seen in other conditions and is not diagnostic. 
The spinal symptoms are more to be relied upon for diagnosis than are 
the cerebral symptoms. The mind in some cases remains perfectly clear ; 
in others there is delirium, but seldom continuous, deep coma. 

At its beginning, cerebrospinal meningitis may be confounded with 
pneumonia or other diseases with cerebral symptoms. It is differentiated 
with certainty only by lumbar puncture. It is sometimes difficult to 
distinguish cerebrospinal from tuberculous meningitis and from acute 
poliomyelitis with meningeal symptoms. Cerebrospinal meningitis is 
relatively infrequent except in epidemics. The fluid is usually turbid 
and contains many cells of the polymorphonuclear variety ; in tuberculous 
meningitis the fluid is clear and the few cells found are nearly all lym- 
phocytes. Tuberculous meningitis may occur anywhere or at any time. 
Its characteristics are a gradual onset with indefinite symptoms, low 
temperature, persistent drowsiness, irregularity of pulse and respiration, 
absence of active delirium, late coma, less marked hyperesthesia and 
rigidity, duration seldom over three weeks from the beginning of definite 
cerebral symptoms, termination invariably fatal. Cerebrospinal menin- 
gitis, however, frequently ends in recovery, and it is the only form of 
acute meningitis which does so. In poliomyelitis the spinal fluid resem- 
bles that of tuberculous meningitis. 

Treatment. — Flexner's serum for the treatment of cerebrospinal 
meningitis is more effective in controlling the disease than any other 
measure thus far proposed. It is obtained by immunizing horses with 



CEREBROSPINAL MENINGITIS 



739 



toxins and cultures obtained from many strains of the meningococcus. 
It acts chiefly on the bacteria themselves ; i. e., it is a bacteriolytic serum. 
It is used as follows : After withdrawing by lumbar puncture all the 
fluid that will flow readily, under the strictest aseptic precautions, the 
serum, warmed to the body temperature, is injected without removing 
the needle. In some exceedingly sensitive patients the administration of 



Day 
104° 

103° 

102 ° 

101 ° 

100° 

99 ° 

98 ° 


2 


3 


4 


5 


6 


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Day 


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10 


_eucocytes 




20,400 


25,600 


15,000 


16,400 


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12,500 


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20,000 


Serum 
Injected 


40c.c. 


30 


35 


30 










Fluid 
Removed 


80 c.o. 


40 


40 


40 






55 




20 


Nature 
of Fluid 


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Turbid 


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Few 


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None 



Fig. 96. — Cerebrospinal Meningitis Treated by Serum. Infant, 7 months old, 
Babies' Hospital: 24 hours ill; intense prostration; respiration, 80; signs of pul- 
monary edema; general relaxation; stupor; profuse hemorrhagic eruption. First 
fluid, purulent; amount removed, amount of serum injected, and the changes in 
the fluid shown in the chart. Immediate improvement in symptoms after first in- 
jection. Subsequent symptoms typical. A rise in temperature on the 8th day 
and the increase in leucocytes on the 9th and 10th days suggested relapse; but 
as the fluid was clear and no organisms could be found in smears or by culture no more 
serum was given; complete recovery. 

a h'\v whiffs of chloroform may be accessary. The injection is made by 
gravity, using a rubber tube and small funnel. It should be made very 
slowly, occupying several minutes. Raising the hips facilitates the inflow 
of the serum. To be effective, it must be brought into contad with the 
organisms in the spinal canal in a considerable degree of concentration. 
The initial dose of the serum now used is 10 to 15 c. c. for infants, 
and 15 to 25 c. c. for children from two to twelve years old. The dose 
is usually repeated in twenty-four hours (in very severe cases in twelve 



740 



DISEASES OF THE NERVOUS SYSTEM 



hours) and a daily dose thereafter "until four or five have been given. The 
indications for further injections are: continuance of marked nervous 
symptoms, persistence of temperature, persistence of leucocytosis and of 
great numbers of polymorphonuclear cells in the cerebrospinal fluid, 
even though no organisms are found in smears and there is no growth 
from cultures. To introduce more serum than the amount of fluid with- 
drawn is somewhat hazardous. In the milder cases it sometimes hap- 
pens that a single dose may suffice for a cure; but even in such cir- 
cumstances it is safer to give at least three doses on successive days. 
The serum arrests the inflammatory process by destroying the organisms 
which produce it. To accomplish this a sufficient dose must be given, 
and given early, before important inflammatory changes have taken place. 



Day 1! 


i 19 


,2Q, 


21 


22 


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24 


, 25 


26 


27 


28 


29 


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32 


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Fig. 97. — Cerebrospinal Meningitis. Late injection of the serum, prompt effect; 
complete recovery. Boy, 11 years, St. Vincent's Hospital, New York. Early symp- 
toms obscure, and on account of swelling and pain in joints diagnosis of rheuma- 
tism made; cerebral symptoms not marked. First lumbar puncture made on 31st 
day and meningococcus found. Serum injected on the 34th and 35th days. Rapid 
fall in the temperature followed by cessation of all symptoms and complete recovery. 

An immediate effect of the injection is seen in the cerebrospinal 
fluid. There is a marked reduction in the percentage of polymorphonu- 
clear cells. The number of meningococci is greatly reduced and their 
vitality lessened. After the first injection they stain with difficulty, and 
after a second injection it is generally impossible to grow them, although 
they are usually present in small numbers (Fig. 96). The effect on the 
symptoms is often striking. There is a marked reduction in the temper- 
ature, which may amount to three or four degrees in twenty-four hours, 
and it may not rise again (Fig. 1)7). The stupor and delirium often 
diminish rapidly, and soon disappear. Improvement is also seen in the 
patient's general condition, pulse, and respiration. The last symptoms 
to be affected are usually the rigidity of the neck and extremities. 

Intraspinal injections are not wholly devoid of danger. A moderate 
degree of shock following the procedure is quite common. The child's 
head should be lowered and he should be closely watched for half an hour 



CEREBROSPINAL MENINGITIS 741 

or more. In rare instances more serious symptoms are seen, usually in 
the nature of an acute failure of respiration. Alarming symptoms gen- 
erally come on quite abruptly with little warning, and unless promptly 
recognized and energetically treated death may follow. A number of 
theories have been advanced in explanation of these phenomena, but it 
seems clear that they are due to the changes produced in the intra- 
cranial pressure. If the symptoms develop while serum is being 
injected, the funnel should be lowered and some of the fluid siphoned 
out of the canal. Atropin should be given hypodermic-ally and artificial 
respiration employed energetically. We have seen but a single fatal 
result, but in several instances it was necessary to use artificial res- 
piration for fifteen or twenty minutes before normal respiration was 
established. It is evident that the greatest care should be used in in- 
jecting serum and that the possibility of the development of serious 
symptoms should always be kept in mind. A close observation of the 
blood pressure during the injection has been advocated by Sophian; its 
fall furnishes a warning of the development of serious symptoms. Our 
own experience leads us to the belief that it is of some value, but that 
very careful watching of the child's pulse and respiration answers quite 
as well. 

The results of this treatment show a much larger percentage of re- 
coveries than has been obtained by any other method. 1 Of 1,500 cases 
of all types, in patients of all ages treated by this serum, the general 
mortality was about 25 per cent. The figures represent results ob- 
tained in many epidemics in all parts of the world. The statistics from 
this country are not so favorable as those from abroad with the same 
serum, for the reason that in the results here are included reports from 
many physicians who, without experience in the use of the serum, treated 
Inii one or two cases. The foreign statistics, however, are in larger 
groups, and the cases for the most part were under the care of men who 
had had experience with the serum. In the epidemic in France fche 
mortality of the cases not treated by serum was about TO per cent, 
while in those receiving serum it was but 1"> per cent. This indicates 
what, may be expected with serum treatment under favorable conditions. 
One of the most striking evidences of tin' value of this treatment i< the 
results obtained in infants under one year. Without serum these cases 
have almost invariably terminated fatally; with scrum over 50 per cent 
of them have recovered. 

The results are much modified by fche time of injection as Bhown by 
the following table : 

1 For details, see articles by Flexner and hi- associates in the Journal of Ex- 
perimental Medicine, from September, 1908, to 1915. Reliable serum can he ob- 
tained from the New York Health Department. 



'42 



DISEASES OF THE NERVOUS SYSTEM 



Time of Injection 


Flexner. 
(All sources, 
chiefly U. S.) 


Netter. (France.) 


Dopter. (France.) 


1st to 3d day 


14.9% 

22.0% 
36.4% 


7.14% 
11.1 % 
23.5 % 


8.2% 


4th to 7th day 


14.4% 


After the 7th day 


24.1% 







In better's series Flexner's serum was used; Dopter used the serum 
prepared at the Pasteur Institute. 

The effect on the course and duration of the disease is no less marked 
than that upon the mortality. The duration of acute symptoms is very 
much shortened, and in about one-fourth of the cases the disease termi- 
nated by crisis (Fig. 97). This is more often seen in cases injected 
early, although it is observed in some injected as late as the fourth 
week. The infrequency of complications and sequelae is also noteworthy. 
Not only do patients recover, but they recover quickly, and in most in- 
stances completely. The absence of complications and sequelae is, no 
doubt, to be explained partly by the effect of the serum in shortening the 
disease. 

Eelapses occur in a small proportion of the cases. They are due to 
the fact that the organisms have not been entirely destroyed by the 
serum. They are usually indicated by a rise in temperature, an increase 
in the leucocytosis, and an aggravation of the nervous symptoms. They 
are to be treated like a primary attack, daily injections being repeated 
so long as organisms and symptoms persist. 

Yery little improvement is to be expected in patients who have 
passed the febrile stage and who are suffering chiefly from the effects 
of distention of the ventricles due to a chronic basilar lesion. The most 
unpromising early cases are those of the fulminating type which have 
usually advanced so far before the serum is given that recovery is im- 
possible. Unpromising also are cases in which a very thick purulent 
fluid is present which can hardly be withdrawn through the needle. The 
amount which can be removed is usually very small. The diffusion of 
the serum in the canal is difficult. In such cases Eobb (Belfast), before 
injecting the serum, has used with success irrigation of the spinal canal 
with a warm sterile salt solution. In some cases, particularly in infants, 
when the withdrawal of fluid by lumbar puncture has been impossible 
owing to adhesions or other causes, fluid may be removed by puncturing 
the ventricles of the brain through the fontanel. The serum is then in- 
jected into the same cavity. The procedure is not difficult, and, if 
carefully done, attended by little risk. We have used it in several cases. 
The effect of the serum seemed quite as marked as when it was introduced 
in the usual manner. 



ACUTE MENINGITIS DUE TO OTHER CAUSES 743 

In any case suspected to be cerebrospinal meningitis lumbar punc- 
ture should be made as early as possible. If the fluid obtained is puru- 
lent or only .slightly turbid, the serum should be injected at once. If 
the fluid is clear, the disease is probably not cerebrospinal meningitis, 
and one may wait for a bacteriological report. Meningitis due to the 
pneumococcus, the bacillus of influenza, or to pyogenic organisms, may 
also give a purulent fluid, but no harm would result from using the serum 
in such a case, although no benefit should be expected. 

The injection of various chemical agents (protargol, lysol, etc.) has 
from time to time been advocated ; but the experimental work of Flexner 
and Amoss has shown that such substances are absolutely without value 
and may even diminish the chances of natural recovery. 

Lumbar puncture per se has some slight therapeutic value. It re- 
lieves pressure and by reducing the number of microorganisms may have 
a slight effect upon the inflammatory process, especially when used early ; 
but in most cases this is only temporary. An ice-cap should be applied 
to the head, and at times an ice-bag along the spine. The bowels should 
be kept freely open. Treatment otherwise is directed toward the symp- 
toms of the disease. Severe pain requires morphin or codein sometimes 
in quite large doses. For other nervous symptoms — delirium, sleepless- 
ness, etc. — the bromids and chloral, sulfonal, or trional may be given, 
or warm sponge or tub baths. Stimulants are indicated by a weak, rapid, 
and irregular pulse. Caffein and digitalis or strophanthus should be 
used, but not strychnin. 

The nutrition of the patient is important. Feeding is often difficult, 
and gavage may be advantageously employed. Bed-sores should be pre- 
vented by cleanliness, frequently changing the patient's position, etc. 
Retention of urine may require the use of the catheter. 

For the residual paralysis, massage, warm baths, and friction should 
be employed, but electricity only when all symptoms of central irritation 
have subsided. The prolonged use of iodic! of potassium, especially in 
combination with mercury, seems to have some value. 



ACUTE MENINGITIS DUE TO OTHER CAUSES 

Besides the main varieties of acute meningitis, viz., that due to the 
meningococcus and thai due to the tubercle bacillus, ' there are* other 
forms differing in etiology, lml closely related clinically, and therefore 
they may be advantageously considered together. It is only since the 
general adoption of lumbar puncture as a means of diagnosis that these 
forms of meningitis have been clinically differentiated. Formerly they 
were grouped under the somewhat indefinite heading of "simple menin- 



744 DISEASES OF THE NERVOUS SYSTEM 

gitis." Three of these varieties, those due to the pneumococcus, the in- 
fluenza bacillus, and pyogenic organisms, are sufficiently important to 
require separate description. Cases of meningitis due to the typhoid 
bacillus, the gonococcus, and the colon bacillus, have all been reported 
in children, but are so rare as only to deserve mention. 

Pneumococcus Meningitis. — This is the most important variety in- 
cluded in this group and the one most frequently met with in young 
children. In our hospital patients about ten per cent of the cases of acute 
meningitis were of this form. Nearly all had pulmonary symptoms of 
greater or less severity, usually a definite pneumonia with consolidation ; 
several had also empyema. Less frequently, pneumococcus pericarditis 
and peritonitis have been present. Occasionally pneumococcus meningitis 
is seen when there are no definite pulmonary symptoms or signs and 
when it is apparently a primary inflammation. However, in most cases 
pneumococcus meningitis is one of the results of a generalized pneumo- 
coccus infection. In every one of our cases of pneumococcus meningitis 
in which cultures of the heart's blood were made at autopsy, this or- 
ganism was present. It was usually found in blood cultures made during 
life. This form of meningitis occurs in infants more frequently than 
in older children, and, in our experience, usually in very young infants; 
over half of the cases seen were in patients under six months old. While 
the disease usually develops at the height of an attack of pneumonia, it 
may precede the pulmonary symptoms and it may develop during con- 
valescence. We once saw it as late as the fourth week. 

Lesions. — In a general way the anatomical changes resemble those 
described in cerebrospinal meningitis, with the exception that the marked 
changes in the brain substance which are usually dependent upon 
the long course of that disease are wanting. As a rule, also, the lesions 
are limited to the brain. If the cord is involved, it is only to a slight 
degree. 

Acute meningitis due to the pneumococcus is characterized by a more 
abundant exudation of fibrin and pus than is seen in any other variety 
of meningitis. The lesion may affect the entire brain, but it is espe- 
cially marked at the convexity and over the anterior lobes. Sometimes 
it is limited to these regions, the meninges of the base escaping. The 
exudate may be so abundant as almost to conceal the convolutions. (See 
Plate XI.) There is usually less distention of the ventricles than in 
cerebrospinal meningitis. 

In cases apparently primary, or when meningitis occurs very early in 
the course of a general pneumococcus infection, the symptoms are usually 
indistinguishable from those of ordinary cases of cerebrospinal menin- 
gitis. It is generally not until lumbar puncture is made that the variety 
of meningitis is suspected. When meningitis occurs as a secondary in- 



PLATE XI 




Acute Pneumococcus Meningitis, Complicating Pleuropneumonia 
Child twenty months old; on twenty-third day of a protracted attack of pneumonia, 
vomited six times, and the temperature, which had been Dearly normal for four days, 
rose to 103° F. On the following day general convulsions, which were repeated frequently 
(lining the next few days; temperature, 101° to 104° F.; death in convulsions on twenty- 
eighth day. 

Autopsy. — Pleuropneumonia of left side; lung resolving. Anterior portion of brain 
enveloped in lymph and pus, more marked at the convexity, but present also over the base. 



ACUTE MENINGITIS DUE TO OTHER CAUSES 745 

flammation it is often latent, and not infrequently is found at autopsy 
when not suspected during life. Usually, however, the meningeal compli- 
cation is indicated by the abrupt development, in the course of an attack 
of pneumonia, of vomiting or convulsions, followed by active delirium or 
stupor. Because the lesion is principally, sometimes only, at the con- 
vexity, many of the symptoms belonging to meningitis with basal lesions 
are absent. There is rarely cervical opisthotonus; the fontanel may not 
be bulging; pulse and respiration may not be disturbed, in fact, there 
are no cranial-nerve symptoms and the symptoms due to spinal in- 
volvement — hyperesthesia, rigidity, Kernig's sign, etc. — are usually want- 
ing. 

The course of pneumococcus meningitis is generally short and acute, 
death taking place within three or four days from the first symptoms. 
We have several times seen a prolonged type of the disease lasting many 
weeks; one case ended fatally near the end of the third month; another 
patient recovered from the acute symptoms, but remained partially par- 
alyzed and mentally defective. 

The diagnosis of pneumococcus meningitis can positively be made 
only by lumbar puncture. The cerebrospinal fluid in gross appearance 
does not differ from that seen in cases due to the meningococcus. The 
cells present are chiefly polymorphonuclear. Pneumococci are very 
abundant and are easily found in smears and grown readily in cultures. 
The existence of pneumococcus meningitis is not always shown by lumbar 
puncture. We have met with one case in which repeated punctures gave 
negative results, and yet the autopsy showed meningitis to be present, 
but only the convexity was affected. The organisms were readily found 
in the meningeal exudate. 

Influenza Meningitis. — This form of meningitis in many respects 
resembles the form just described. According to Wollstein, 1 there 
had been recorded, up to 1911, 49 cases of pure, and 9 cases of 
mixed, influenza meningitis. Of these, 28 were in infants under one year 
old. Since then many additional cases have been reported. The disease 
is certainly not very rare. Of the cases which have come under our 
own observation, all hut one have been in infants and all have ended 
fatally. In our experience, influenza meningitis has been secondary to 
other influenza infections, usually those of the rhinopharynx or bronchi. 
The organisms were found by culture from the secretions of these parts 
during life. One patient, an infant of eight months, was admitted to the 
hospital with an acute abscess of the elbow joint. Two days Inter symp- 
toms of meningitis developed, and death occurred in three days. The 
autopsy showed an extensive purulent meningitis. Pure cultures of the 

1 American Journal of Diseases of Children, January, 1911. 



746 DISEASES OF THE NERVOUS SYSTEM 

influenza bacillus were obtained from the pus of the elbow, the fluid 
drawn by lumbar puncture, the meningeal exudate, and the heart's blood. 
The lungs showed influenza bacilli and streptococci. 

The lesions of influenza meningitis, in the few cases in which autop- 
sies have been made, have differed in no essential particular from those 
described in the pneumococcus variety. In the cases coming under our 
observation in which examinations were made, the influenza bacillus 
was obtained from the 5 heart's blood as well as from the cerebrospinal 
fluid. 

Clinically, influenza meningitis usually runs a short, very acute 
course. There are no features by which it can be distinguished from the 
pneumococcus or meningococcus form, except the findings of lumbar 
puncture. In gross appearance the fluid does not differ from that seen in 
the other forms. There is usually marked turbidity ; the cells are abun- 
dant and of the polymorphonuclear variety. The organisms are gen- 
erally not numerous in the smears, in marked contrast to the other 
forms of meningitis. They are readily grown upon blood agar, but not 
upon ordinary media. If, therefore, from a turbid cerebrospinal fluid 
no growth occurs, influenza meningitis should be suspected. 

Meningitis Due to Pyogenic Organisms — Septic Meningitis. — Menin- 
geal inflammations set up by the streptococcus or staphylococcus are 
not very common in young children. They are almost always secondary. 
In the newly born this form of meningitis is seen in general pyemia, 
usually from umbilical infection; it also follows infection of a spina 
bifida. In older children it follows injuries to the head, erysipelas of 
the scalp, operations upon the brain, and otitis media with mastoiditis 
or sinus thrombosis. Such a complication of otitis in infancj 7 is, how- 
ever, extremely rare. The lesions consist in a widespread general in- 
flammation of the pia with an abundant exudate of pus, but with less 
fibrin than in the two varieties previously described. 

The symptoms of septic meningitis are not distinctive. The course 
is usually a rapidly progressive one, and the termination almost invari- 
ably in death. The fluid drawn by lumbar puncture in most cases is 
markedly turbid, and shows great numbers of pus cells. The organisms 
are present in large numbers and are readily recognized both in smears 
and by cultures upon ordinary media. 

Diagnosis. — The differential diagnosis of the different forms, of 
meningitis from each other, and from other diseases with cerebral symp- 
toms, is made with certainty only by means of lumbar puncture, which 
should be done in all cases of doubt. The appearance of the cerebrospinal 
fluid is essentially the same whether the inflammation is due to the men- 
ingococcus, the pneumococcus, the influenza bacillus, or to the staphylo- 
coccus or streptococcus. The symptoms of meningitis in general, de- 



TUBERCULOUS MENINGITIS 747 

scribed in the chapter on Cerebrospinal Meningitis, are present in most 
of the cases. 

Prognosis and Treatment. — The prognosis in all varieties of acute 
meningitis, except that due to the meningococcus, is very bad; almost 
every case of meningitis due to other causes is fatal. From what has 
been said, it would appear that treatment is as yet most unsatisfactory, 
and is only symptomatic. Wollstein's researches at the Eockefeller In- 
stitute, however, indicate that influenza meningitis may occasionally be 
controlled by serum treatment. A goat serum has been produced which 
regularly controls the experimental disease in monkeys. Its use in chil- 
dren has thus far been very seldom successful, since there is usually a 
general influenza septicemia and since the disease is so rapid in its course 
that an early diagnosis is rarely made. 



TUBERCULOUS MENINGITIS 

(Acute Hydrocephalus; Basilar Meningitis) 

Tuberculous meningitis is a tuberculous inflammation of the pia 
mater of the brain, sometimes involving also that of the cord. It is by 
far the most frequent form of acute meningitis seen in young children. 
In our hospital experience, apart from epidemics of cerebrospinal menin- 
gitis, seventy per cent of the cases of acute meningitis have been tuber- 
culous. It is more uniformly fatal than any other disease of early life. 
It is doubtful if it ever occurs as the only tuberculous lesion of the body. 
In infancy it is usually associated with general or pulmonary tubercu- 
losis; in older children with tuberculosis of the bones, joints, or lymph 
nodes. Of our own cases, forty per cent of all deaths from tuberculosis 
in children have been due to meningitis. 

Lesions. — The lesion consists in the production of miliary tubercles, 
with which are frequently found tuberculous nodules of variable size, and 
in almost every case there are also the products of ordinary inflammation 
of the pia mater — fibrin and pus — together with an accumulation of 
fluid in the lateral ventricles of the brain. Frequently there are tubercles 
in the pia mater of the upper portion of the cord. When few in Dumber 
the tubercles are usually only at the base. When numerous they are seen 
scattered over the convexity. Tubercles are frequently -found in the 
choroid coat of the eye. The amount of fibrin and pus in the exudate 
is usually small, and is much less than is seen in other forms of acute 
meningitis. The inflammatory products are most ahundanl ai the base. 
In addition to the patches of greenish-yellow fibrin, there are adhesions 
between the lobes of the brain and thickening of the pia. In cases which 



748 DISEASES OF THE NERVOUS SYSTEM 

have lasted for several weeks, this thickening may be marked, owing 
to cell infiltration and the production of new connective tissue. The 
pia is studded with miliary tubercles, sometimes with small yellow 
tuberculous nodules; frequently there is arteritis, which is sometimes 
obliterating. 

In the most acute cases the brain substance immediately beneath the 
pia is intensely congested, slightly softened, and shows under the micro- 
scope a superficial encephalitis. The Lateral ventricles are usually dis- 
tended with clear serum, sometimes with serum containing flocculi of 
fibrin or pus ; the amount present varies from one to four ounces in each 
ventricle, being always greater in the subacute cases. The walls of the 
ventricles may be softened. The distention of the ventricles leads to 
flattening of the convolutions from pressure against the skull, to bulging 
of the fontanel, and sometimes to separation of the sutures. 

Tuberculous nodules varying in size from a small pea to a walnut are 
frequently seen associated with meningitis in older children, but not 
often in infants. These nodules may be connected with the meninges, 
or they may be situated within the brain substance, usually in the cere- 
bellum. The larger ones are classed as brain tumors. Inflammatory 
products are rarely found in the spinal canal. 

Although it is not infrequent to see meningitis without symptoms of 
tuberculosis elsewhere, we have never failed at autopsy to find other 
tuberculous lesions in the body. In our experience the following are 
those most often met with, given in the order of frequency: (1) In in- 
fants, associated with general or pulmonary tuberculosis; (2) in chil- 
dren from three to twelve years of age, with tuberculosis of the vertebrae, 
hip, knee, or ankle; (3) at any age, with tuberculosis involving only 
the tracheal, bronchial, or mesenteric lymph nodes; (4) much less fre- 
quently with the pulmonary tuberculosis of older children. 

Etiology. — Tuberculous meningitis is produced only by the transpor- 
tation of the tubercle bacilli to the brain. They may find their way 
by the blood-vessels or by the lymphatics. 

The following table shows the age at which the disease was observed 
in 410 cases of which we have notes : 

Under one year 162 

One to two years 149 

Two to five years 76 

Five to nine years 17 

Nine to sixteen years 6 

Total 410 

In this series three cases were in children three months old or 
younger. Tuberculous meningitis in our experience occurs much more 
often in the winter and spring months than at other seasons (Fig. 98). 



TUBERCULOUS MENINGITIS 



749 



The most plausible explanation of this seems to be that these patients, 
infected some time previously, carry a latent focus of tuberculosis some- 
where in the respiratory tract, usually in the bronchial glands. Under 
the influence of acute respiratory infections of the cold season, the latent 
tuberculous disease becomes active, and a rapidly spreading tuberculous 
process results. In infants and young children it rarely happens that 
pulmonary lesions are absent; but these patients are especially predis- 
posed to early meningeal infection, and this often occurs before symp- 
toms of tuberculosis elsewhere have manifested themselves. At the time 
of invasion, therefore, most of these children are apparently in the best of 
health. In older children there may have been previous evidence of tuber- 



1400 
1200 
1000 
800 
600 
400 
200 





JAN. 


FEB. 


MAR. 


APR. 


MAY 


JUNE 


JULY 


AUG. 


SEPT. 


OCT. 


NOV. 


DEC. 


55 


























50 


























45 


























40 


v 


/ 






















35 


X 


V 






















30 








\ 

\ 
















? 


25 


V, 




/ 

• 


> 


\ 
\ 












y 


/ 


20 




>* 






\ 












^~ 




15 












X 








y 


S 




10 














V, 




^ 








5 
















-«^„ 






































1400 
1200 
1000 
800 
600 
400 
200 



Fig. 98. — Seasonal Occurrence of 400 Cases of Tuberculous Meningitis. 
Lower Curve, Deaths from Pneumonia New York City, one year. 

culosis in lungs, bones, or lymph nodes. The modes of acquiring tubercu- 
losis are discussed in the general chapter on that disease. It is sufficient 
to say here that it is usually from some member of the family or house- 
hold. This may be not only a person who is in the active stage of pul- 
monary tuberculosis, but one who is supposed to have been cured or one 
in whom the disease has not yet been suspected. Exposure may antedate 
symptoms by several weeks or months. Striking evidence in favor of fche 
human origin of tuberculous meningitis is obtained from a study of the 
type of tubercle bacillus present in cases of meningitis. In thirty-two 
cases in our series, this was worked out by Park and Krumwiede in fche 
Research Laboratory of the New York Health Department. In thirty 
the bacillus was of the human type; in one it was of the bovine type, 
and in one both types were present. 

Symptoms. — In about two-thirds of the cases the onset is gradual; 



750 DISEASES OF THE NEKVOUS SYSTEM 

but in a considerable number of those classed as abrupt, careful inquiry 
will elicit a history of previous indisposition. The most frequent early 
nervous symptoms are, disinclination to play, drowsiness, or sometimes 
constant fretfulness or irritability. Often there is a complete change in 
disposition. In a case under our observation this was most striking; 
a little girl previously devoted to her mother, could not endure her 
presence in the room. Sleep is restless and disturbed; there may be 
grinding of the teeth. Older children often complain of headache. At 
all ages, but particularly in infancy, early digestive symptoms are prom- 
inent. There are seen frequent attacks of vomiting without apparent 
cause; the bowels are generally constipated and the appetite is almost 
entirely lost. Usually there is also a slight but continuous elevation of 
temperature. Indefinite symptoms may last for four or five days, or 
they may be spread over two or three weeks without perhaps being suf- 
ficiently severe to attract much notice. Finally, unmistakable evidence 
of brain disease develops. The early disturbances are often ascribed to 
dentition, or to indigestion. 

In most cases the first pronounced cerebral symptom is persistent and 
increasing drowsiness; exceptionally it is an attack of general convul- 
sions, followed in a few hours by stupor. Often a period of irritative 
symptoms is present, lasting several days. There is headache, usually 
located in the frontal region, and occasionally photophobia; sometimes 
pain is indicated by the child's suddenly screaming out at night, which 
may be repeated many times without waking ; sometimes during the 
greater part of the time for two or three days these frequent screaming 
attacks may be repeated. The skin is somewhat hyperesthetic ; the re- 
flexes are apt to be exaggerated; the muscles of the neck may be rigid 
and the head is drawn back, or there may be rigidity of the extremities. 
The pupils are normal or contracted; there may be nystagmus. The 
child is fretful, wishes to be left alone, and cries if disturbed. In some 
cases these symptoms are so marked as strongly to suggest cerebrospinal 
meningitis. They may alternate with periods of marked apathy and 
dulness. During this stage there is occasional vomiting, and the bowels 
are obstinately constipated. The pulse is usually somewhat accelerated, 
but may be slow and occasionally it is irregular. The respiration is of 
normal frequency, but a careful observation during sleep or perfect quiet 
will often show a distinct irregularity which is very significant. The 
temperature is usually elevated, ranging from 99° to 100.5° F. When 
a high temperature is seen, it is usually due to tuberculosis elsewhere 
than in the brain. 

As the disease advances, the irritative symptoms subside, and the stu- 
por becomes deeper and more continuous. If undisturbed, the child may 
sleep a great part of the time, but can be roused, and then appears 



TUBERCULOUS MENINGITIS 751 

quite rational. Finally the stupor becomes so profound that the child can 
not be roused at all. Active delirium is rare. The pupils respond slowly 
to light or not at all; they may be unequal; occasionally there is seen 
strabismus, ptosis, or paralysis of the face. More often there is hemi- 
plegia, or paralysis of one arm or leg. Such paralyses are often transient, 
disappearing after a day or two. Automatic movements of the extremi- 
ties, particularly of the arms, are frequent. Muscular twitchings may 
be noticed. Opisthotonus is marked and well-nigh constant. In infants 
the fontanel is tense and bulging. In older children especially, the ab- 
domen is retracted, giving the typical "boat-belly/' After drawing the 
finger-nail along the skin of the abdomen, there appears a distinct red 
streak, which remains for several minutes. This is the tache cerebi-rffe. 
and it is almost always present. Other vasomotor disturbances may be 
seen. The reflexes are variable; in the early part of the disease they are 
usually increased, later they are diminished or abolished. The pulse now 
becomes slow and irregular, 

often intermittent. The res- ^yvWL^^MA/LvvnMi 
piration is almost always ir- 
regular; a very characteristic FlG - ^.-Tracing of ^Respiration in Tuber- 
& ' J culous Meningitis. 

type consists in the movements 

becoming deeper and deeper until there is a sigh; followed by a complete 
arrest of respiration for several seconds. The phenomenon is then re- 
peated. The accompanying tracing illustrates the type (Fig. 99). An 
examination with the ophthalmoscope usually shows the presence of 
choked discs, and in a very considerable number of the cases, if they are 
closely studied, tubercles may be seen in the choroid. Their presence is 
of much diagnostic importance. The blood picture in this disease is 
fairly characteristic. From 230 observations made in the Babies' Hospi- 
tal, it was shown that early in the attack the total leucocytes are only 
slightly increased, they may be even below the normal. As the disease 
progresses they increase in number, the average during the last week of 
the disease being 29,600. The proportion of polymorphonuclears also 
shows a marked increase. The early range was 60 to 65 per cent; during 
the last week it was from 70 to 85 per cent. 

The progress of the disease is subject to great variations, especially 
in children over two years old. The advance of symptoms is slower and 
is interrupted by periods of remission which may continue two or three 
days. After being in quite deep stupor, a child may recover conscii >us- 
ness, and even sit up and play with toys, leading to the view Hi;)' an 
error in diagnosis has been made. But this respite is only temporary; 
soon the child passes again into coma. 

Fr< in this time the duration of the disease is from three i<> ten days. 
The child can not be roused at all. The pupils arc widely dilated, and 



752 



DISEASES OF THE NERVOUS SYSTEM 



do not respond to light. There is general muscular relaxation. There 
may be retention of the urine. Deglutition is difficult, often impossible. 
The respiration is more rapid, but still irregular. The pulse becomes 
very rapid and feeble, often 160 to 180 a minute. Toward the end the 
temperature often rises rapidly to 104° F., sometimes to 106° or 107° F. 
(Fig. 100). Death usually takes place from exhaustion in deep coma, 
or convulsions develop and continue from twelve to twenty-four hours 
until death. Sometimes a patient will live for days in a condition of 
prostration so extreme that death is hourly expected. A rapidly rising 
temperature or the occurrence of late convulsions usually indicates ap- 
proaching death. Of fifty-seven cases, fifty died in coma, seven in con- 



DAY 




1 


2 


3 


4 


5 


c 


7 


8 


9 


10 


11 


12 


13 


14 


15 


1 6 


17 


DATE 


OCT. 


10 


11 


12 


13 


14 


IS 


16 


17 


18 


19 


20 


21 


22 


23 


24 


25 


26 


I 
z 

K 

I 
< 
U. 

u? 

EC 

D 
H 
< 

a. 
S 
Ul 

H 


106° 
105° 
104° 

103° 
102° 
101° 
100° 
y9° 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 


M.E. 
/ 


































/ 
































A A 


J 






























/ 


V 






h 


v 


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f 


k/ 






A 


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V 


V 


A 


IV 


L 


V 


J 


V 






















V 






V 

















































Fig. 100. 



-Fairly Typical Temperature Curve in Tuberculous Meningitis. 
Boy, twenty months old; death on seventeenth day. 



vulsions. The entire duration of the disease from the beginning of 
definite nervous symptoms is rarely over three weeks, and in infants it 
is usually shorter than this. 

Diagnosis. — Tuberculous meningitis is often overlooked because the 
patients do not give outward evidences of tuberculosis. Its fre- 
quency should always lead one to suspect it when protracted nervous 
symptoms are present in infants. There are no diagnostic symptoms in 
the early stage. The indefinite symptoms that belong to this stage of 
the disease are frequent in young children suffering from chronic indi- 
gestion associated with constipation. Cases of cyclic vomiting may 
present many of the symptoms of meningitis. 

The most diagnostic symptoms of tuberculous meningitis enumerated 
in the order of their frequency are as follows: persistent drowsiness, 
obstinate constipation, vomiting without apparent cause, irregular respi- 
ration, irregular pulse, convulsions, opisthotonus, and fever which is 
usually slight. A positive diagnosis is made only by lumbar puncture; 
by this means this form is distinguished from other forms of acute 



TUBERCULOUS MENINGITIS 753 

meningitis. The fluid drawn by lumbar puncture is usually perfectly 
clear, but sometimes after standing there is a slight deposit present. 
In rare cases the fluid may be turbid. As compared with the other forms 
of acute meningitis the cells are few in number. The usual cell count 
is from 100 to 250 per c. mm. Nearly all the cells, over 95 per cent in 
most cases, are mononuclear. ' Very exceptionally the polymorphonuclear 
cells are greatly in excess. The presence or absence of sugar has been 
in our experience of no diagnostic importance. 

Tubercle bacilli are almost invariably present in the fluid, although 
in the early stage they are few in number and often difficult to find. 
But at the height of the disease by careful examination they can be 
found microscopically in nearly every case. They were found in 135 
of 137 consecutive cases of tuberculous meningitis at the Babies' Hospi- 
tal. They are more numerous late in the disease. 

The technic is important. Fluid should be drawn into several 
tubes and the last one containing 15 to 20 c.cm. set aside for examination, 
as the bacilli are much more likely to be found in this. The tube 
should not be shaken, but should be allowed to stand for twelve hours, 
preferably in an incubator. A central fibrin coagulum generally forms in 
the fluid, and in this the bacilli are usually entangled. This should be 
spread out entire and carefully examined. In other cases the bacilli 
may be found after centrifuging. In most of the cases the number of 
bacilli present is not large and a search of half an hour to an hour is 
necessary; but not infrequently they are so numerous that they are 
discovered in a few minutes. 

The Boss-Jones 1 and Noguchi globulin tests are useful in distin- 
guishing inflammatory from normal cerebrospinal fluids. They are, 
however, of no value in distinguishing between the different forms of 
meningitis. A positive reaction is obtained with great uniformity in 
every variety of acute meningitis. 

Bacilli have been found in the sputum, in our experience, in nearly 
one-half the cases in infants and young children with tuberculous menin- 
gitis, although in most of them there was little or no evidence of pul- 
monary disease. 

The v. Pirquet cutaneous test gives reliable information except in 
moribund cases, in those excessively prostrated or with very poor circula- 

1 Lancet, May 8, 1909, p. 113. 

A few cubic centimeters of a completely saturated solution of pure am- 
monium sulphate arc placed in a test tube and 1 c.c. of cerebrospinal fluid is 
gently run on to the surface. A positive reaction is indicated by the formation 

of a ring at the point of contact of the two fluids. The ring is grayish white and 
sharp. It should form within three minutes. Indirect illumination should be 
used for its detection. 



754 DISEASES OF THE NERVOUS SYSTEM 

tion. A positive reaction was obtained in 161 of 194 cases tested. This 
test is of much assistance in early diagnosis. 

If, then, a child with symptoms distinctly meningeal gives a positive 
reaction to the tuberculin test the probabilities of tuberculous meningitis 
are greatly strengthened, even though at the time bacilli may not have 
been found in the cerebrospinal fluid. 

The cerebral symptoms of intestinal and many other acute diseases 
sometimes closely resemble those of tuberculous meningitis. From all 
such the diagnosis is made by lumbar puncture. In any case of men- 
ingitis in a young child the chances are greatly in favor of the tuber- 
culous form, since it is much more frequent. The diagnosis from cere- 
brospinal meningitis and acute poliomyelitis is considered under those 
diseases. Differentiation from the meningeal form of poliomyelitis may 
be very difficult, owing to the similarity of the spinal fluid in the two 
diseases. 

Prognosis. — Although there have been recorded a few instances of 
recovery after tubercle bacilli have been found in the fluid obtained 
by lumbar puncture, such an outcome is not to be expected. We have 
never seen such a case recover. The reported recoveries in which 
the diagnosis has rested upon clinical symptoms only, can not be 
accepted. 

Treatment. — From what has been said regarding prognosis, it follows 
that if the diagnosis is correct the case is practically hopeless, no matter 
what treatment is employed; but as a positive diagnosis is not always 
possible, all cases should be treated like other forms of acute meningitis. 



CHRONIC BASILAR MENINGITIS IN INFANTS 

It was first pointed out in 1898 by Still that this disease is usually 
due to the diplococcus intracellularis ; in other words, that it is a chronic 
form of cerebrospinal meningitis. Chronic basilar meningitis is most 
frequently seen after epidemics of cerebrospinal meningitis, but it is 
occasionally met with at other times as a sequel of a sporadic case. It 
occurs after an acute attack, when the basilar lesion persists, and be- 
comes chronic. As acute cerebrospinal meningitis in infants is usually 
fatal if the attack is severe, it follows that the chronic form is seen 
only after the mild attacks. It is chiefly for this reason that the early 
symptoms often are not recognized as those of cerebrospinal meningitis. 
The patient frequently does not come under observation until all acute 
symptoms have passed away, the persistent opisthotonus being the chief 
feature of the case. 

There is also seen in children, though very rarely, a' chronic basilar 



CHRONIC BASILAR MENINGITIS IN INFANTS 755 

meningitis of syphilitic origin. Several such cases have come under 
our observation. 

Lesions. — This process is usually limited to the base of the brain. 
The pia mater is thickened about the interpeduncular space, also over 
the medulla, pons, and cerebellum. It may be adherent to the inner 
surface of the dura. The foramina of Magendie and of Luschka are 
usually obliterated, and there results a distention of the lateral ventricles 
with clear serum, sometimes in sufficient amount for the case to be re- 
garded as hydrocephalus. Barely, pus may be found in the ventricles. 
There may be a cystic formation at the base of the brain due to the accu- 
mulation of fluid in one of the cisterns of the pia. In such circumstances 




*1W 



• 



Fig. 101. — Chronic Basilar Meningitis — Extreme Deformity. Ill for five months; 
followed cerebrospinal meningitis; posture shown in the picture was maintained for 
the last six weeks; death at ten months. Autopsy showed typical lesions. 

the cerebellum is often much compressed by the fluid. The cranial nerves 
may also be compressed. 

Symptoms. — The onset is usually gradual, although in most cases 
there can be obtained a fairly distinct history of an early active period. 
The most prominent symptoms are cervical opisthotonus, moderate hy- 
drocephalus, and usually general muBcular rigidity. The opisthotonus is 
often extreme ( Fig. 103 ) and is greater than is seen in any other disease. 
If placed upon his hack the body of the child often touches the table only 
at the occiput and the sacrum (Fig. 102). The head is usually some- 
what enlarged, hut never to the degree seen in primary hydrocephalus; 
the fontanel bulges, and the sutures are separated. These symptoms 
are due to an accumulation of fluid in the lateral ventricles. The rigidity 
of the extremities is very greal ami in most cases constant ; the legs and 



756 DISEASES OF THE NERVOUS SYSTEM 

feet are usually extended, while the forearms are flexed and the hands 
clenched. All the reflexes are greatly exaggerated. There is rarely 
coma, but mental dulness alternating with periods of great irritability 
in which general convulsions may occur. Vision may be impaired or 
wanting entirely. The fact that in most of the cases optic neuritis is 
absent is of some value in differentiating this disease from tumor. Nys- 
tagmus is often present and attacks of vomiting occur without evident 
cause. There is no fever except for a few days at a time during acute 
exacerbations. Fluid obtained by lumbar puncture is often clear but 
usually contains a slight excess of cells and the globulin reaction is pos- 
itive. Occasionally turbid fluid may be obtained and there may be found 




Fig. 102. — Chronic Basilar Meningitis. A patient in the Babies' Hospital (diagnosis 

confirmed by autopsy). 

a small number of meningococci, both intra- and extra-cellular. The 
usual duration of the disease is from two to five months; death may 
occur from convulsions, or from some intercurrent disease, such as pneu- 
monia, but most frequently from marasmus. The prognosis is very bad 
except when the cause is syphilis, when recovery may take place. 

Diagnosis. — The disease is to be distinguished from tuberculous 
meningitis, and from the opisthotonus of reflex origin which is occa- 
sionally seen in infants suffering from marasmus. It differs from tuber- 
culous meningitis in its more protracted course, in the absence of fever 
and paralysis, and also in the greater prominence of the opisthotonus and 
hydrocephalus. 

Treatment. — If meningococci are found, anti-meningococcus serum 
should be used. It will usually destroy the organisms, although it can- 



THROMBOSIS OF THE SINUSES OF THE DURA MATER 737 

not affect the pathological changes that have taken place as the result of 
their long activity. If there is any reason to suspect syphilis, salvarsan 
and the iodid of potassium and mercury should be administered. Opera- 
tions for the relief of the hydrocephalus have, up to the present time, 
met with little measure of success. 



THROMBOSIS OF THE SINUSES OF THE DURA MATER 

This is not of very frequent occurrence. It may depend upon certain 
general conditions, when it is usually classed as cachectic or marantic 
thrombosis; it may be associated with local pathological processes, when 
it is known as inflammatory or septic thrombosis. 

Cachectic Thrombosis. — This is seen in infants and young children, 
but is very rare after the age of five years. It occurs in the course of 
various diseases, the most frequent being pneumonia, pertussis, diph- 
theria, nephritis, tuberculosis, and the acute intestinal diseases. In 
connection with the last-mentioned group, altogether too much has been 
made of it, as it is really rare, and in only a very few cases does it explain 
the cerebral symptoms present. The actual cause of the thrombosis is 
the altered condition of the blood and the feeble circulation, as the walls 
of the sinuses are normal. 

The most frequent seat of cachectic thrombosis is the superior longi- 
tudinal sinus. At autopsy one must be careful not to confound the soft. 
partly decolorized, non-adherent thrombi of post-mortem origin, with 
those of ante-mortem formation. The latter are firm, and when of long 
standing may be very hard and even show a laminated structure. They 
usually fill the sinus completely, and are adherent. The thrombus ex- 
tends from the sinuses to the veins emptying into it, which si and out 
like dark worms upon the surface of the brain. The brain itself may he 
deeply congested, or it may be covered with a diffuse hemorrhage, hut 
more frequently the brain and the membranes are simply edematous. 

The symptoms of cachectic thrombosis are few and uncertain, and in 
a large Dumber of cases the disease is latent. Very rarely is a positive 
diagnosis possible during life. When the thrombosis occurs just before 
death, its symptoms are so mingled with those of the original disease 
that they can not he separated. In some cases there inav he localized 
or general convulsions, or paralysis, loss of consciousness, and stra- 
bismus. 

The prognosis is had, cases generally proving fatal in the course of a 
few (lavs. The diagnosis is so uncertain and obscure that the treatment 

must he symptomatic, and directed toward the general rather than the 
local condition. 



758 DISEASES OF THE NERVOUS SYSTEM 

Inflammatory Thrombosis — Septic Thrombosis — Sinus-Phlebitis. — 

This condition is most frequently seen in children in connection with 
acute meningitis. It may exist either with the simple or the tuberculous 
variety. It also follows otitis — especially old and neglected cases — usu- 
ally with necrosis of the petrous bone, but sometimes without it. It is 
much less frequently associated with disease of the ear in children than 
in adults. It may arise from traumatism, necrosis of the cranial bones, 
or from septic processes involving any of the cavities or any of the 
structures adjacent to the brain, such as the scalp, orbit, nasal fossa, 
mouth, or pharynx. Infection from the mouth or pharynx is most fre- 
quent in children in connection with scarlet fever or diphtheria; while 
usually secondary to otitis it may occur without it, the infection being 
carried by the blood-vessels. Infection from the nose may have its 
origin in ulceration from syphilis or tuberculosis. In the orbit, the 
source may be malignant disease. 

The seat of the thrombosis will depend upon the original disease. If 
this affects the cranial bones or the scaJp, it will be the longitudinal 
sinus; if the ear, the lateral sinus; if the base of the skull, the orbit, 
the mouth, the jaw, or the nose is affected, it will be the cavernous sinus. 
When thrombosis occurs with meningitis the lesions are much the same 
as in the cachectic form, with the exception that there are sometimes 
slight changes in the walls of the sinuses. If the patient has suffered 
from a local septic process, there may be puriform softening of the 
clot, and general pyemia, with the development of secondary abscesses 
in the brain, in the lungs, and in other organs. With such cases there 
may be associated a general or localized meningitis. 

Symptoms. — The symptoms of septic thrombosis are more definite 
than those of the cachectic form. When occurring in the course of men- 
ingitis, it usually adds no new symptoms \o those of the original dis- 
ease. In the pyemic form the symptoms are more characteristic, par- 
ticularly when associated with otitis. There are recurring chills with 
very high and widely fluctuating temperature. There is headache, and 
often localized tenderness of the scalp; the other symptoms which are 
present are usually the same as those of meningitis. If metastasis oc- 
curs, there may be evidences of abscesses in the brain or in other organs, 
and sometimes there are signs of suppuration in the jugular vein. A 
polymorphonuclear leucocytosis is usually present, and blood cultures 
in most cases show the presence of pyogenic organisms. 

The local symptoms of the thrombosis differ somewhat according to 
the sinus affected: if its seat is the superior longitudinal sinus, there 
may be cyanosis of the face, dilatation of the temporal and frontal veins, 
and sometimes epistaxis ; if the lateral sinus is involved, the process may 
extend to the jugular vein, which may be felt in the neck as a hard 



CEREBRAL ABSCESS 759 

cord, and there may be dilatation of the veins of the mastoid region, and 
even localized edema ; when the cavernous sinus is affected, there may be 
protrusion of the eyeball of the affected side, edema of the lid, and with 
the ophthalmoscope the retinal veins appear enlarged and tortuous, some- 
times being the seat of thrombosis. The process may affect either one 
or both sides. The course of septic thrombosis is rather irregular, vary- 
ing from a few days to three weeks. In fatal cases death takes place 
from meningitis, cerebral abscess, or pyemia. The prognosis is very 
grave unless the disease is so situated that it is accessible to surgical 
operation. 

Treatment. — The only successful treatment is surgical. Operation 
is easiest in thrombosis of the lateral sinus, being much more difficult 
if involving the superior longitudinal sinus. So many cases are now on 
record of successful operation upon septic thrombosis of the lateral sinus 
that it should always be urged when the diagnosis is clear. 



CEREBRAL ABSCESS 

Cerebral abscess is quite rare in children, decidedly more so than is 
cerebral tumor. In Gowers' collection of 223 cases, only twenty-four 
were under ten years of age. Tn infants, abscess is one of the least fre- 
quent, diseases of the brain, and up to five years it is exceedingly 
rare. 

Etiology. — By far the most frequent cause in children is otitis. This 
is the origin of the great majority of the cases. Abscess rarely compli- 
cates acute otitis, but is seen with the chronic form. Exactly how otitis 
causes cerebral abscess it is not always easy to determine. Usually 
there is caries of the petrous bone, but there may be none. The infection 
may extend through the small veins traversing this bone, or along the 
lateral sinuses to the cerebellum. Abscess is often attributed to the re- 
tention of pus in the ear, but it may occur when the discharge is free. 

We have seen in a young infant abscess follow nasal infection, the 
process apparently extending through the cribriform plate of the eth- 
moid. 

Traumatism is the second important etiological factor. Abscess may 
be associated with fracture of the skull, or follow simple concussion. The 
abscess is generally in the neighborhood of the injury, but occasionally 
is produced by contre coup. Abscess may be the result of infectious 
emboli, associated with general pyemia, though this is rare in early life; 
and finally it may occur without any assignable cause. The organisms 
usually present are streptococci, staphylococci, or pneumococci. 

Lesions. — The mosl frequenl seal of the abscess is, first, the tem- 



760 DISEASES OF THE NERVOUS SYSTEM 

porosphenoidal lobe; secondly, the cerebellum: thirdly, the frontal lobes. 
Other locations are very rare. Abscesses are usually single. In size they 
vary from that of a small cherry to an orange. We have seen a case in 
an infant in which one whole hemisphere was replaced by several large 
abscesses with thick walls, only a thin layer of cortex covering them. 
No cause for them could be found and the pus was sterile. The con- 
tents are usually thick greenish-yellow pus, which may be very fetid. 
When abscesses have lasted for some time they are usually surrounded 
by a dense pyogenic membrane, and may become encysted. The patholog- 
ical process may be slow, and often is apparently stationary for a long 
period. Abscesses may rupture into the ventricles, less frequently upon 
the surface of the brain, causing meningitis, or the pus may even escape 
externally through the auditory meatus. 

Symptoms. — These are general and local. The general symptoms are 
much the more important for diagnosis, and often are the only ones 
present. The local symptoms are those of a tumor. The clinical history 
of a case of abscess of the brain may be divided into three stages ; First, 
the period of onset, or early acute inflammatory symptoms, fever, etc., 
*which attend the formation of pus. Secondly, the latent period, or period 
of remission, in which very few symptoms are present; in many acute 
cases this stage is wanting altogether; in the chronic cases it may last 
for months, or even years. Thirdly, the final period, with recurrence 
of active cerebral symptoms, followed by death in a few days. 

The onset may be accompanied by symptoms so slight as almost to 
escape notice. In most cases, however, headache and fever are present. 
The headache is usually severe, and often localized upon the affected 
side ; in cerebellar abscess it may be occipital. The fever is moderate in 
intensity, and continuous. In addition there may be vertigo, vomiting, 
general convulsions, and cessation of the aural discharge, if one has 
been present. The duration of this stage is variable; it may be only a 
few days, or several weeks. It is shorter in traumatic cases, and in 
those which are due to pyemia. 

The latent stage, or period of remission of symptoms may be quite 
short — only a few days' duration — and it is often absent. During this 
period the temperature may fall quite to the normal, and the headache 
disappear, or be only occasional and slight. However, if any focal symp- 
toms have been present they remain unchanged. 

The symptoms of the terminal stage are due to a rapid extension of 
the inflammatory process, with edema and softening about the abscess, 
sometimes to rupture into the ventricle, and sometimes to meningitis. 
The fever now returns, and may be high. There is headache, often 
very intense and continuous ; there may be delirium and convulsions, and 
the gradual development of coma. In addition there may be vomiting, 



CEREBRAL ABSCESS 761 

paralysis, opisthotonus, retracted abdomen, and the other symptoms of 
meningitis. Occasionally all the earlier symptoms may be latent, and 
the terminal symptoms may be the only ones present. In infants, the 
fontanel is usually large and bulging; convulsions are rather more fre- 
quent than in older children. 

The local symptoms of abscess are rather indefinite, owing to its 
usual situation. Abscesses of considerable size may exist in the temporo- 
sphenoidal lobe, in the central part of the frontal lobe, or in the cere- 
bellum, without any definite local symptoms. If the abscess is near 
the motor area, there are the usual symptoms of disease in this location : 
spasm, or paralysis of the face, arm, or leg. A cortical or subcortical 
abscess is likely to cause convulsions. Cerebellar abscess may give rise 
to occipital headache, frequent vomiting, and when the abscess is large 
enough to press upon the middle lobe, there may be incoordination of 
the muscles of the extremities. Optic neuritis may be present, but other 
symptoms relating to the cranial nerves are rare. Localized tenderness 
over the scalp, when persistent, is a symptom of importance, and may 
serve to locate the abscess, if it is superficial. 

Diagnosis. — Of the general symptoms, the most important for diag- 
nosis are fever, headache, delirum, and terminal coma. These become 
particularly significant when following otitis or traumatism. The dif- 
ferential diagnosis of abscess is to be made principally from tumor and 
meningitis, and from these conditions more by the history and general 
course of the disease than by any special symptoms. The diagnosis of 
abscess from tumor is considered in connection with the latter dis- 
ease. It is more difficult to distinguish between meningitis and abscess. 
since the two processes are often associated. With meningitis convul- 
sions are more common, but they are rarely localized; rigidity and the 
inflammatory symptoms arc more intense; the course is usually more 
rapid and more regular, being rarely interrupted, as is the course of 
abscess. Leucocytosis is more constant and usually more marked in 
meningitis. Lumbar puncture gives negative results in uncomplicated 
abscess while it gives positive definite information in meningitis. 

Prognosis. — The prognosis in cerebral abscess is always grave, unless 
accessible to surgical operation. The progress may be slow, or rapid, bul 
it is inevitably from bad to worse, and sooner or later the disease, if not 
interfered with, proves fatal. 

Treatment. — The medical treatment of abscess in its active stage is 
that of any acute intracranial inflammation — ice to the head, absolute 
quiet, free catharsis, and full doses of the bromide or morphin, if pain 
is intense. The absolutely hopeless condition of these eases when left 

to themselves, and the recent brillianl results from surgical operations, 
should lead the physician to urge operation in every caae. 



762 DISEASES OF THE NERVOUS SYSTEM 

CEREBRAL TUMOR 

Tumor of the brain is not very infrequent, and may be seen even in 
infancy. From this time up to puberty there is no period of special 
susceptibility. In 269 of the cases in Starr's collection, in which the 
nature of the tumor was stated, the following were the varieties : 

Tubercle 152 cases 

Glioma 37 " 

Sarcoma 34 " 

Gliosarcoma 5 " 

Cyst 30 " 

Carcinoma 10 " 

Gumma 1 " 

269 cases 

Tuberculous tumors are more often multiple than arc other varieties. 
Their most frequent seat is the cerebellum; next to this the pons and 
crura cerebri. They are occasionally cortical or central. Glioma is most 
often found in the cerebellum or in the pons, and next in the cortex ; it is 
rarely central. Sarcoma is most frequently in the cerebellum; next to 
this, in the order of frequency, in the pons, the basal ganglia, and the 
cortex. Cystic tumors are either central or cerebellar. Taking the 
cases as a whole, the most frequent seat of tumors in children is : first, 
the cerebellum ; second, the pons ; third, the centrum ovale. They rarely 
spring from the cortex. 

Tuberculous tumors are occasionally seen in infancy, but they occur 
most frequently between the ages of four and twelve years. They are 
always secondary to tuberculosis elsewhere, usually of the lungs and 
of the bronchial lymph nodes. They most frequently start from the 
membranes, rarely being centrally situated, and extend inward, infil- 
trating the superficial portion of the cerebellum or cerebrum. In more 
than half of the cases they are multiple. There is almost invariably 
localized meningitis at the site of the tumor; there may be adhesions 
between the dura and pia mater, and the disease may extend to the 
cranial bones. In size these tumors vary from a small pea to a child's 
fist. They may be softened and broken down at the center, or cheesy 
throughout. They are the result of a localized tuberculous inflammation, 
which does not differ essentially from that seen in other parts of the 
body. They rarely undergo calcification. 

Glioma is not infrequent in infancy. It repeats the structure of 
the neuroglia, being composed of connective tissue and branching cells. 
It is an infiltrating tumor whose limits are difficult to determine even 
under the microscope. 

Sarcomata may be of almost any variety. They grow much more 



CEREBRAL TUMOR 7G3 

rapidly than gliomata. The two varieties are very occasionally combined 
in the same tumor — gliosarcoma. 

Cystic tumors may be the result of porencephalic softening or of 
encapsulated hemorrhages in early life. Gliomata and sometimes sar- 
comata undergo cystic softening. Cysts may be parasitic in origin. The 
cause of many simple cysts is entirely obscure. They may be found in 
any part of the brain. 

Carcinomata are always metastatic and are secondary to a primary 
growth elsewhere than in the brain. Gummata and vascular tumors are 
exceedingly rare until after puberty. 

As the tumor grows, secondary lesions are produced in most of the 
cases. These are the result of pressure on contiguous parts of the brain 
interfering with their function, or of obstruction to the aqueduct of 
Sylvius or the fourth ventricle preventing the exit of fluid from the in- 
terior of the brain and thus causing hydrocephalus. Tumors in the pos- 
terior fossa are very frequently accompanied by hydrocephalus. Local- 
ized meningitis over tumors superficially situated is the rule, and this 
may be the cause of some of the symptoms. Rarely, cerebral hemorrhage 
may be associated. 

Etiology. — The causes of cerebral tumors are for the most part 
unknown. In a few instances there is a history of definite traumatism. 
Sarcomata may be secondary, carcinomata and tuberculous tumors are 
probably always so. 

Symptoms. — These may be divided into two groups: first, the general 
symptoms, which are common to tumors of all varieties, are chiefly due 
to pressure and are more or less independent of location; secondly, the 
local symptoms depending upon the situation of the growth. 

Of the general symptoms one of the most frequent is headache. 
Though it varies much in its severity, character, and position, it is 
rarely absent. It is apt to be severe, and may continue for a long 
period, or it may be intermittent. The location of the pain has no 
definite relation to the situation of the tumor, nor is the intensity of the 
pain dependent upon the size of the tumor. It may be accompanied 
by sensations of tightness, compression, or tension in the head. It may 
be associated with localized tenderness of the scalp ; when this is constant 
it is a valuable symptom for diagnosis, as it often occurs with tumors 
superficially located. 

General convulsions are frequent in the early stage, but separated 
by quite long intervals; they become more frequenl and more severe 
as the disease progresses. All degrees of severity are seen, from slight 
twitehings and temporary loss of consciousness to typical epileptiform 
seizures. They are most common when the growth is rapid and when 
complicating meningitis is present. Attacks of vomiting or of localized 



764 DISEASES OF THE NERVOUS SYSTEM 

spasm may for a considerable time precede general convulsions ; and in a 
single attack there may be first localized and then general convulsions. 

Mental symptoms are generally present in great variety and com- 
plexity. There may be only fretfulness and irritability, or a marked 
change in disposition. These symptoms are so frequent from other 
causes in children that they excite no apprehension, unless to them are 
added dulness, apathy, and somnolence. Later in the disease there may 
be attacks of melancholia or there may be periods of wild, almost 
maniacal, excitement ; and, finally, the mental impairment may approach 
a condition of imbecility. 

Disturbances of sleep are frequent. There is usually insomnia, but 
sleep may be broken by hallucinations, accompanied by attacks of 
screaming; rarely is there persistent drowsiness until toward the end of 
the disease. 

Optic neuritis or papillo-edema (choked disc) is very frequent, occur- 
ring in 80 to 90 per cent of the cases. This is only recognized by the 
ophthalmoscope, as there may be no disturbance of vision. The choked 
disc is generally double. It is nearly constant with tumors of the 
posterior fossa, especially of the cerebellum. It is also very frequent 
with tumors of the corpora quadrigemina and of the parietooccipital 
region. Papillo-edema is usually associated with tumors of the basal 
ganglia, but is late in appearance or frequently absent with tumors 
of the pons, corpus callosum or convexity. 

Vomiting is a very frequent symptom, but diagnostic only when it 
occurs suddenly without assignable cause, and without nausea or other 
symptoms of indigestion. Usually attacks come several days apart, often 
occurring early in the morning. Vomiting is especially significant when 
frequently repeated, and of more importance in older children than in 
infants. 

Vertigo is often associated with vomiting. At first it is occasional 
and seen upon changing position, but later it may be quite constant, 
especially with tumors in the posterior fossa. 

A slow pulse is occasionally observed with brain tumors. It may be 
as low as 40 or 50 to the minute. This is the result of increased intra- 
cranial pressure, and is only found when the pressure is great. It 
is therefore usually a late symptom. Enlargement of the head, secondary 
to the hydrocephalus, at times occurs. It is more apt to be found before 
the fontanel has closed and the sutures are firmly ossified, but separation 
of the sutures and marked enlargement of the head may take place as 
late as the eighth or tenth year. Pressure of the tumor may cause 
erosion of the contiguous bone. The most frequent seat of this erosion 
is the sella turcica with tumors of the pituitary. This can often be 
made out by the X-ray, which also shows frequently separation of the 



CEREBRAL TUMOR 765 

sutures and digital markings on the skull, the result of hydrocephalus. 
Very infrequently the shadow of a tumor is revealed. Diabetes insipidus 
is a symptom occasionally associated with tumors at the base, especially 
when the pituitary is involved. 

Local Symptoms. — These depend upon the situation of the tumor, 
but not at all upon its character. They are the result of pressure or of 
destruction of brain tissue. They may therefore be irritative or paralytic 
symptoms. Local symptoms may be wanting entirely, and they may 
vary much in different cases even with tumors in the same situation. 
They are modified by the size and by the rapidity of growth, and by the 
existence of localized meningitis. 

Tumors situated in the frontal lobe, as a rule, present few symptoms 
and may be entirely latent. Irritation of the frontal lobe may extend 
to the motor area and cause convulsions either local or general; but 
not often is there paralysis. Tumors of the left side (of the right side 
in left-handed persons) may cause apraxia, and when in the third frontal 
convolution, motor aphasia. 

Tumors in the motor convolutions along the fissure of Rolando 
produce the most definite and uniform local symptoms. When situated 
at the upper portion the leg is affected, at the middle portion, the arm, 
and at the lower, the face. Irritative symptoms, such as rigidity or 
clonic spasm, commonly precede for some time the paralysis which re- 
sults from pressure or destruction. These attacks of localized convulsions 
begin in the face, arm, or leg; but they usually extend more or less 
rapidly until all three are involved. They are often followed by slight 
transient paralysis. Consciousness is often retained and when lost is lost 
late in the attack. Such attacks are known as "Jacksonian epilepsy," and 
form one of the most diagnostic symptoms of cerebral tumor. Localized 
spasm may be associated with anesthesia or other disturbances of sensa- 
tion. The paralysis generally first affects one extremity — the arm or leg, 
according to the location of the tumor — and afterward it may involve 
the entire; side, including the face. 

If the tumor is centrally located, or at the base, hemiplegia may be 
an early symptom from pressure on the motor tract. With cortical 
paralysis there may be associated ataxia and paresthesia or anesthesia. 

Tumors of the parietal lobe may give no local symptoms. If flic 
tumor is deeply situated there may be hemianopsia from pressure on 
part of the optic tract. If the inferior parietal lobule of the left side 
is affected, there may be word-blindness, or inability to understand writ- 
ten language. 

Tumors of the occipital lobe produce, as the only constanl local 
symptom, hemianopsia. This is usually bilateral, affecting the same side 
of both eyes, being on the side opposite to that of the lesion, i. e., a 



766 DISEASES OF THE NERVOUS SYSTEM 

tumor on the right side causes blindness in the left half of both eyes, 
so that the patient sees nothing to the left of a line directly in front 
of him. Instead of hemianopsia, there may be only irritation and various 
disturbances of sight. 

Tumors of the temporosphenoidal lobe may be latent, or, if on the 
left side, may cause word-deafness, i. e., inability to understand the 
significance of spoken language. 

Tumors in the island of Eeil when situated upon the left side 
(right side in left-handed persons) may cause motor aphasia or disturb- 
ances of speech. If they are large they may produce symptoms by 
pressure upon the motor tract — hemiplegia or monoplegia. 

Tumors of the basal ganglia cause marked general symptoms, but 
none of a definitely local character. The important symptoms relate to 
the various tracts or bundles of fibers which pass from the cortex through 
the internal capsule. These include the motor and the various sensory 
tracts, the olfactory, auditory, visual, and speech tracts. Any of these 
may be pressed upon, and the nature of the symptoms will depend upon 
the size of the tumor and the extent of the pressure. If only the 
anterior part of the capsule is affected there may be no symptoms ; if the 
middle fibers, hemiplegia and disturbances of articulation ; if the posterior 
fibers, hemianesthesia. All these may be associated, and any of them 
may be complete or partial. Tumors in this situation are apt to im- 
plicate the cranial nerves. Optic neuritis is quite constant, but may 
not appear early. Localized or general convulsions are rare. 

The peculiar symptoms pointing to tumors of the crura cerebri are 
nystagmus, strabismus, and loss of pupillary reflex, sometimes with gen- 
eral muscular incoordination, and a staggering gait. There is usually 
third-nerve paralysis on the side of the tumor, and on the side opposite 
to the hemiplegia with which it is often associated. This variety of 
crossed paralysis is quite diagnostic. The symptoms of third-nerve 
paralysis are external strabismus, dilatation of the pupil, and ptosis. 
While hemiplegia is commonly present with large tumors, it may be 
absent with small ones, or may appear later than paralysis of the third 
nerve. 

Tumors of the pons are quite common. The diagnostic symptoms 
consist in crossed paralysis, the cranial-nerve symptoms being on the 
side of the tumor, and the general motor and sensory symptoms on 
the opposite side. When the seat is the upper half of the pons, the third 
and fifth nerves are apt to be implicated, giving rise to ptosis, dilatation 
of the pupils, external strabismus, trophic disturbances such as ulcera- 
tion of the cornea, and neuralgic pain in the face. Tumors in the lower 
half of the pons involve the sixth, seventh, and eighth nerves, causing 
internal strabismus, contracted pupils, facial paralysis, sometimes deaf- 



CEREBRAL TUMOR 767 

ness, and auditory vertigo. Other symptoms associated with tumors of 
the pons are headache, vomiting and optic neuritis; convulsions being- 
rare. 

Tumors of the medulla are recognized by the involvement of the 
glossopharyngeal, pneumogastric, spinal accessory, .and hypoglossal 
nerves. There is difficulty of deglutition, irregular respiration, irregu- 
lar pulse, and vasomotor disturbances, such as flushing of the face and 
perspiration. There may be projectile vomiting, polyuria or glycosuria, 
opisthotonus, difficulty in articulation or in sucking, and in protrusion 
of the tongue. Hydrocephalus is often marked. These tumors may 
produce symptoms of pressure upon the motor or sensory tracts — paraly- 
sis, or partial anesthesia, with rigidity and exaggerated reflexes. 

Tumors of the pituitary gland or in the immediate neighborhood 
may give characteristic symptoms. These are referred to hypopituitar- 
ism, a decrease in the function of the anterior lobe of the pituitary. 
There may be a marked deposition of subcutaneous fat with a tendency 
to mental dulness and with a retardation of sexual development at the 
time of puberty. This is frequently spoken of as "Frohlich's syndrome.*' 
In some children with these symptoms there is an increased sugar 
tolerance so that as much as 150 grams of glucose may be taken at one 
time without glycosuria. These symptoms are usually found with benign 
growths. Malignant growths such as sarcomata are destructive and 
usually produce no such syndrome. Symptoms frequently associated 
with pituitary growths are bitemporal hemianopsia from pressure on 
the optic chiasm and later amblyopia. There may be paralysis of the 
extraocular muscles. Headache is not a striking symptom and hydro- 
cephalus is inconstant. Acromegaly is rarely seen in children. 

Tumors of the cerebellum arc especially important, tins being ttie 
most frequent location in childhood. When only one hemisphere is 
affected there may be no local symptoms. Tumors involving the middle 
lobe, or those large enough to produce pressure upon the middle lobe. 
give rise to vertigo and cerebellar ataxia. Vertigo is especially frequent : 
it may be associated with headache. Cerebellar ataxia is different from 
the ataxia due to a spinal-cord lesion, and strikingly resembles lliat of 
intoxication. It may increase until the patient is unable to walk, 
although there is no loss of muscular power. Vomiting is a frequent 
symptom, as are also optic neuritis and headache, which is usually 
occipital. When there is secondary hydrocephalus, as is usual, mental 
symptoms are present, and there may he enlargement of the head, opis- 
thotonus is occasionally seen, bul general convulsions arc rare. 

Course. — This is usually progressive toward a fatal termination. 
The rapidity depends much upon the character of the growth. Malig- 
nant tumors, especially sarcomata, may cause death in a lew weeks. 



768 DISEASES OF THE NERVOUS SYSTEM 

Tuberculomata may give symptoms for many months but are usually 
fatal before that time from general miliary tuberculosis or tuberculous 
meningitis. Occasionally symptoms of brain tumor may be present for 
several years without any distinct advancement and then with a sudden 
increase of symptoms death may take place in a few days. 

Diagnosis. — Cerebral tumor may be confounded with abscess, chronic 
basilar meningitis, and chronic hydrocephalus. The symptoms distin- 
guishing tumor from abscess are the following: Tumor may occur at 
any age; without definite etiology, excepting when tuberculous; the 
progress is steady, but generally slow, new symptoms being continually 
added; headache is more constant and more severe; optic neuritis more 
frequent; cranial nerves more often involved; mental disturbances more 
marked; focal symptoms are often definite; fever and leucocytosis are 
absent ; duration, six months to two years. As compared with the above, 
abscess is not so frequent, being especially rare in infancy; there is a 
definite history of traumatism or ear disease ; progress more irregular ; 
symptoms often intermittent; headache less severe; mental symptoms 
less marked; optic neuritis and involvement of the cranial nerves less 
frequent; focal symptoms usually indefinite; fever and leucocytosis 
present except in the latent period; the most frequent complication 
is acute meningitis. 

Chronic basilar meningitis may produce symptoms almost identical 
with those of tumor in the posterior fossa. It is, however, confined to 
infancy; hydrocephalus and opisthotonus are much more marked than 
are usually seen with tumor. An examination of the fluid obtained by 
lumbar puncture will assist much in the diagnosis. 

Chronic hydrocephalus may resemble tumor; this occurs so fre- 
quently as a lesion secondary to tumor that the question often arises 
whether there is only hydrocephalus, or there is in addition a tumor. 
Hydrocephalus is often congenital, is usually encountered in the first 
year of life and commonly attains to a greater degree than is seen in 
secondary hydrocephalus. There is an entire absence of focal symp- 
toms. Papillo-edema is rare but optic atrophy very common. 

A diagnosis of brain tumor should not be made from the presence 
of Frohlich's syndrome alone. The association of the general symptoms 
of tumor with hemianopsia or amblyopia or deformity of the sella tur- 
cica, is necessary. Many children show adiposity, sluggishness and a 
moderate delay in the development of the secondary sexual characteris- 
tics and eventually manifest nothing abnormal. A diagnosis as to the 
nature of a tumor is very difficult, but some information upon this point 
may be gained from the consideration of its etiology, the rapidity of 
its growth and the age of the patient. 

Prognosis. — The prognosis of cerebral tumor is very bad. In the 



HYDROCEPHALUS 709 

overwhelming majority of cases the progress is steadily downward until 
death. Cases are occasionally seen which exhibit all the characteristic 
symptoms of tumor, even including optic neuritis, which recover per- 
fectly. We have seen several such cases. They are probably not tumors 
but circumscribed areas of encephalitis that undergo complete resolu- 
tion. An arrest of the growth very occasionally occurs in tumors of a 
tuberculous nature and recovery takes place with some function of the 
brain impaired. Such an outcome is distinctly unusual. The calcined 
tubercles that are sometimes found at autopsy have usually given no 
symptoms during life. Very little is to be expected from treatment 
unless the tumor is susceptible of operative interference. 

Treatment. — If there is any reason to suspect syphilis, the iodid of 
potassium should be given in large doses and continued for a long 
period. Except for operative measures the treatment is entirely symp- 
tomatic. The possibility of total removal of a growth in childhood is 
very slight. The chief tumors are either infiltrating (gliomata, sarco- 
mata) or part of a more or less generalized tuberculosis. The most 
favorable tumors for operative removal (endotheliomata) are very infre- 
quent in childhood. The best outlook is probably with cysts. Without 
operation, however, the result is so nearly always in death that if there 
is any possibility of removal of the growth it should be attempted. If 
enucleation of the growtli is not possible, cerebral decompression may 
preserve the sight for a long time and do much to diminish the pain 
and general discomfort. 

HYDROCEPHALUS 

Hydrocephalus, or "water on the brain," consists in an accumulation 
of serum in the cranial cavity. This may be between the dura mater 
and the pia (external hydrocephalus) or in the ventricles of the brain 
(internal hydrocephalus). The former is secondary and is quite rare, 
while the latter is not uncommon. Hydrocephalus may be acute or 
chronic. 

Acute hydrocephalus is secondary to basilar meningitis, which is 
usually of tuberculous origin. The terms tuberculous meningitis and 
acute hydrocephalus are sometimes used synonymously. A moderate dis- 
tention of the ventricle- is frequent in all varieties of acute meningitis. 
The amount of fluid in acute hydrocephalus is not great, there being 
rarely more than three or four ounces present. 

Chronic external hydrocephalus except in its mild form is extremely 
rare, and is nearly always a secondary lesion. It may follow meningeal 
hemorrhage, pachymeningitis, or any lesion causing cerebral atrophy. It 
is seen in its most marked form associated with congenital malforma- 



770 



DISEASES OF THE NERVOUS SYSTEM 



tions of the brain, particularly imperfect development of the hemi- 
spheres. (See Fig. 103.) On incising the dura mater a few ounces, or 
sometimes even a pint, of fluid may escape. The convolutions are 
somewhat flattened, and may be greatly atrophied. Other lesions are 




Fig. 103. — Brain in External Hydrocephalus, Showing Imperfect Development 
of the Hemispheres. Patient three and a half months old; head measured 20 K 
inches ; increase in size, 2 inches in the six weeks before death ; symptoms were typical 
of ordinary internal hydrocephalus. In the picture the small size of the cerebrum A is 
best judged by comparison with the cerebellum B, which is normal. The hemispheres 
were rudimentary; the basal ganglia were normal; the cranial cavity contained 
about one pint of fluid. 

found either in the brain or in the dura mater. External hydrocephalus 
may cause enlargement of the head and separation of the sutures, and 
in fact most of the symptoms of the internal variety; but usually it is 
not severe enough to give rise to any decided symptoms. 



CHRONIC INTERNAL HYDROCEPHALUS 



This is the important variety, and when no qualifying term is 
mentioned this is the form of hydrocephalus which is always under- 
stood. 

Internal hydrocephalus may result from many different diseases of 
the brain and meninges. Tn some the amount of fluid is moderate and 



CHRONIC INTERNAL HYDROCEPHALUS 



771 



its presence adds little or nothing to the symptomatology of the condi- 
tion. Tuberculous meningitis is an example. In others, such as tumors 
of the base of the brain, the collection of fluid may be considerable and 
cause definite symptoms but the primary condition and not the hydro- 
cephalus is the important one. 

Etiology. — The etiology of hydrocephalus in many instances has 
been obscure. This has been largely due to the difficulty of studying 
brains at autopsy on account of the injury that results from their 




pueduct 



Fig. 104. — Sagittal Section of 6 Mos. Old Child, Dying of Hydrocephalus, showing 
Dilated Lateral and Third Ventricles and Obliterated Aqueduct of Sylvius. 
(From Dandy and Blackfan.) 



removal unless special precautions are taken. It has been customary 
to divide eases of hydrocephalus into the primary, when the cause was 
obscure, and secondary, when the cause such as tumor or abscess was 
readily apparent. There is no longer any justification for such a divi- 
sion. It seems now established that internal hydrocephalus is always a 
secondary condition depending upon mechanical causes. The recent 
studies of Dandy and Blackfan have shown that the cerebrospinal fluid 
is formed by the choroid plexus in the lateral, third and fourth ventriclen 
— but that it is hot absorbed there. It passes out of the brain through 
the aqueduct of Sylvius into the fourth ventricle and from there to the 
subarachnoid space by means of the foramina of Magendie and of 
Luschka. There is an automatic regulation of production and ahsorp- 



772 DISEASES OF THE NERVOUS SYSTEM 

tion by means of which the amount of fluid is maintained at the 
proper level. Hydrocephalus results when the aqueduct or the foramina 
are obstructed; or when in consequence of injury to the meninges as a 
result of inflammation, the cerebrospinal fluid can not be absorbed with 
sufficient rapidity from the subarachnoid space. In the latter instance 
the fluid is dammed back toward its source and the greatest pressure is 
thus exerted on the interior of the ventricles. 

Obstruction to the flow from the ventricles is frequently brought 
about by a narrowing or complete absence of the aqueduct. (Figs. 




Fig. 105. — Sagittal Section of Normal Brain of an 8 Months Old Child, showing 
Patent Aqueduct of Sylvius. (From Dandy and Blackfan.) 

104, 105.) This condition must be considered a congenital abnormality. 
Obliteration of the foramina, however, is almost always the result of 
inflammation. This may occur in intra-uterine life or at any time after 
birth. Except for those cases plainly following upon meningococcus 
meningitis, the organism causing the inflammation is unknown. Inter- 
ference with the absorption of cerebrospinal fluid is dependent upon some 
previous meningeal inflammation. It is probable that this in turn may 
be of intra-uterine or extra-uterine origin. No sufficient pathological 
examination of cases due to this cause has been made. It is the opinion 
of Dandy and Blackfan that the diminished absorption is due to adhe- 
sions limiting the size of the subarachnoid space. 



CHRONIC INTERNAL HYDROCEPHALUS 773 

In a large proportion of cases the disease is congenital, hydrocephalus 
beginning in the latter months of infra-uterine life. • Syphilis is re- 
sponsible for a certain proportion of cases. By some authors the propor- 
tion is considered a large one. Sufficient data have not been accumulated 
since the introduction of the Wassermann reaction to justify a conclusive 
statement upon this point. In our own experience the association is not 
frequent , — certainly fully four-fifths of the cases are not syphilitic. 
Heredity is a factor of some importance, as numerous instances are on 
record where two children in the same family have been affected. The 
most obvious explanation seems to be that the same meningeal inflam- 
mation or the same congenital abnormality has existed. 

Hydrocephalus not infrequently develops after successful operations 
upon spina bifida or encephalocele. In such an event it is likely that 
an inadequate meningeal absorption was compensated for by the in- 
creased area afforded by the sac of the spina bifida. When the sac is 
removed the absorption of fluid is no longer adequate. There is no 
reason to believe that neuroses, alcoholism, tuberculosis or consanguinity 
in the parents is responsible for hydrocephalus. The rachitic head has 
been so often mistaken for hydrocephalus that an erroneous notion has 
arisen as to the association of the two diseases. There is no etiological 
connection between them. 

Pathology. — Depending upon the cause and the duration of the con- 
dition the amount of fluid may be small or large. It may be only a 
few ounces or several pints. We have seen three pints in an infant two 
weeks old and five pints in one who died at four months. Much larger 
quantities than this have been reported, but in children living several 
years. In composition the fluid resembles normal cerebrospinal fluid. 
Minor changes have been reported but are not uniform. The fluid may 
be slightly yellow and there may be an excess of cells in cases follow inn 
a recent meningitis. The effusion may become purulent from accidental 
infection resulting from operation, from rupture, or from infection 
through the sac of a complicating spina bifida. 

A satisfactory examination of the brain can only be made if it is 
injected with formalin through the carotid arteries and two or three 
hours allowed to elapse before it is removed. The meninges may be 
normal. Frequently, however, they are thickened and there may be 
adhesions between them and the brain, especially at the base. The cis- 
terna magna may, in this way, be greatly diminished in size or actually 
obliterated and adhesions may close the foramina of Dktagendie and of 
Luschka. The aqueduct of Sylvius may not be demonstrable. Ordi- 
narily this is as large as a small quill. Microscopically, remains of it 
may be found in small islands <>f ependymal cells with or without a 
central opening. A gliosis has obliterated the aqueduct. 



774 



DISEASES OF THE NERVOUS SYSTEM 



The chief changes in the brain result from the distention of the ven- 
tricles by fluid. This continues until the hemispheres are destroyed to a 
greater or less extent. The convexity of the brain thus suffers most. 
The basal ganglia and cerebellum are somewhat flattened but otherwise 
relatively normal. The progressive distention results in a gradual thin- 
ning of the brain substance which forms the ventricular walls; often 
these are found only one fourth of an inch in thickness or the cortex may 
be a mere shell (Fig. 106). The ependyma of the ventricle and the pia 
mater are at times actually in contact, all of the brain tissue having been 
m € ""****. absorbed. The brain in 

~d / ( -2 1 such instances resembles a 

I* JL large double cyst. In less 

marked cases there may be 
only a flattening of the 
convolutions. The fora- 
men of Monro is dilated, 
and occasionally the fora- 
men of Magendie also. 
The septum lucidum is 
greatly thinned or may 
have disappeared. The 
brain is anemic and the 
gray and white substance 
may be indistinguishable. 
The ependyma may be 
normal. It is usually 
somewhat thickened and 
pale, sometimes granular 
and may be infiltrated 
with new cells. The mi- 
croscopical changes are inconstant and not marked. There is a tendency 
to atrophy and disappearance of the ganglion cells. 

The cranium is markedly affected. The bones are often very thin; 
the fontanels are very large and the sutures, especially those of the 
vault, widely separated. There may be a formation of Wormian bones. 
After the removal of the fluid which alone gives it its configuration, the 
head may collapse. It should not be forgotten, however, that hydro- 
cephalus may coexist with premature ossification, in which case the 
head may be small. Pressure of the fluid upon the roof of the orbit 
causes it to become less concave or even convex. When recovery occurs 
the sutures and fontanels may close with the help of the Wormian bones, 
and irregular thickening of the bones of the skull take place. The most 
frequent lesion associated with congenital hydrocephalus is spina bifida; 




Fig. 106. — Vertical Transverse Section of a 
Brain in Congenital Hydrocephalus. From 
a child who died at the age of three weeks. A, 
distended lateral ventricle; B, its descending 
horn. 



CHRONIC INTERNAL HYDROCEPHALUS 77.", 

more rarely there is meningocele or encephalocele. Sometimes there 
are deformities in other parts of the body, such as club foot or hare-lip. 

Symptoms. — Many cases of hydrocephalus are congenital and the 
child may die in utero. At other times the process may be so far 
advanced before birth that Caesarian section or puncture of the head 
may be necessary before delivery is possible. In perhaps the majority 
of cases, no symptoms are observed at birth, or the head is only slightly 
larger than normal. Usually, nothing is noticed until the child is two 
or three months old, when it is discovered that the head is increasing 
in size at an abnormal rate. Instead of the usual half an inch a month 
it may be two or three times this. If the progress is rapid, other symp- 
toms are soon evident — the infant cannot hold up his head, he is lethargic 
and all his perceptions are dulled. Only in rare instances is there blind- 
ness, but there is usually some interference with sight, which is, how- 
ever, very difficult to make out with young infants. A ery rarely there 
is deafness. The pupils are usually contracted and equal, though they 
may be dilated. Xystagmus and convergent strabismus are often pres- 
ent. In severe cases the eyes protrude slightly and are rotated down- 
ward, leaving some of the sclera visible. This gives a very characteristic 
expression and is due to the alteration of the roof of the orbit. If the 
hydrocephalus has developed very rapidly, a papillo-edema is sometimes 
seen. This is, however, exceptional and optic atrophy of greater or 
less extent is the rule. 

There is usually rigidity of the muscles of the extremities, more 
marked in the legs, sometimes also in the arms; the hands being clenched 
with the thumbs adducted. The reflexes are exaggerated. 

For a time the nutrition is well maintained, but when the head 
enlarges markedly, the body wastes and the disproportion between the 
I wo may seem greater than it really is. Convulsions are seldom seen. 
Cases which develop early and progress rapidly rarely live to the end of 
the first year, and are often fatal before six months. The causes of 
death are marasmus, convulsions, intercurrent disease, and rarely rup- 
ture of the head. 

The cases which develop slowly are usually those that follow some 
meningeal inflammation. There may be a history of frank cerebrospinal 
meningitis. Sometimes there is only a history of unexplained lexer 
without symptoms to draw attention to the meninges: When the symp- 
toms develop slowly, the head may he hut little larger than normal. 
The brain seems able to tolerate an almost indefinite amount of pressure 
if this develops gradually. The surprising thing about many of these 
cases is that the distinctly cerebral symptoms arc so few. The more 
readily the bones of the skull yield to pressure, the fewer are the nervous 
symptoms, hence, other things being equal 3 they are less, m$r|cec| when 



776 DISEASES OF THE NERVOUS SYSTEM 

the disease begins before the sutures are firmly ossified than in the later 
cases. A comparatively small amount of effusion may cause very marked 
symptoms in a child two or three years old, while a much larger amount 
in an infant of a year may produce much less disturbance. 

Even though the progress of the disease is slow the development of the 
children is greatly retarded. If the course is progressive, however, death 
eventually takes place, although it may be postponed for many months. 
The special senses are generally not noticeably affected; but intelligence 
in most cases is interfered with, in some only slightly; in others, very 
markedly, while some are idiotic. Contractions of the extremities are 
occasionally seen but usually more of the hands than of the legs. Sensa- 
tion is not often affected. The course is a very chronic one and from 
time to time there may be exacerbation of the symptoms. 

Spontaneous arrest may occur at almost any stage. There may 
remain only a moderate enlargement of the head and fair intelligence, 
or recovery may be delayed until the head has reached an enormous 
size, -and the child, on account of this, quite unable to move. Such an 
outcome, however, is rare. 

Dandy and Blackfan have shown that there are two distinct varieties 
of hydrocephalus, one due to obstruction and the other due to dimin- 
ished absorption of the cerebrospinal fluid. When a solution of phenol- 
sulphonephthalein is injected into the normal ventricle the dye appears 
in the cerebrospinal fluid within five minutes and is absorbed very 
rapidly, so that 15 to .20 per cent of it is excreted by the kidneys in the 
course of two hours. After its injection into the spinal subarachnoid 
space, its appearance in the urine is prompt and from 35 to 60 per cent 
is excreted in the course of two hours. 

In the one variety of hydrocephalus, the 'phthalein, after injection 
into the ventricle, does not appear in the fluid obtained by lumbar 
puncture for a long time, and is excreted by the kidneys very gradually 
and during several days. If it is injected into the subarachnoid space, 
the excretion is as prompt as under normal circumstances. This demon- 
strates that there is an obstruction to the outflow of fluid from the 
ventricles into the subarachnoid space, the cause of which may be mal- 
formations or adhesions blocking the foramina of exit. 

In the other variety, the 'phthalein injected into the ventricle 
appears promptly in the subarachnoid fluid but is excreted by the 
kidneys slowly and when it is injected into the lumbar region of the 
cord, it is also excreted slowly. This delayed absorption is the result of 
inflammation which has injured the meninges and diminished the area 
for absorption. 

Prognosis. — Cases developing soon after birth and progressing rap- 
idly are usually fatal before the end of the first year. It is very rare 



CHRONIC INTERNAL HYDROCEPHALUS 777 

that a hydrocephalic child reaches the age of seven years. The process 
may, however, go on up to a certain age and then cease spontaneously 
and the child may go through life with a head much larger than normal 
and usually with a somewhat impaired mental condition. In others the 
mentality is nearly or quite normal and yet some muscular weakness 
or even paralysis persists. This arrest of hydrocephalus is probably 
brought about by an adjustment which has taken place by which the 
meninges are able to absorb sufficiently to keep pace with the production 
of the cerebrospinal fluid. 

Diagnosis. — The most important symptom is the enlargement of the 
head, and this can only be arrived at by careful measurement and 
comparison with the normal size. The rapidity of growth is quite as 
important for diagnosis as the fact of enlargement. If the head grows 
as much as an inch a month there can be little doubt. The enlarge- 
ment most frequently confounded with hydrocephalus is that which 
occurs in rickets. In the latter disease it is almost invariably irregu- 
lar; there are prominences over the two frontal eminences and over the 
parietal bones, often with furrows between them; the size of the head is 
chiefly due to thickening of the bones of the skull; the marked promi- 
nence of the forehead is not seen, and the increase in the biparietal 
diameter is not present; furthermore, there are other signs of rickets. 

Pachymeningitis interna may be confounded with hydrocephalus. 
The fluid, however, is usually either reddish and reddish-yellow or is 
quite blood-stained and may contain red blood-cells. A differential 
diagnosis may be very difficult. 

Treatment. — If syphilis is suspected, energetic treatment by mer- 
cury and salvarsan should be instituted. In our experience, benefit 
from these has not been very marked and little is to be expected unless 
they are employed very early. Eepeated lumbar punctures have, in a 
small proportion of cases, apparently been of value in bringing about 
an arrest of the process. Since differentiation between the different 
varieties has been possible, we have seen benefit result in cases with 
a free communication between the ventricles and the subarachnoid space. 
On a priori grounds, this is the only variety in which lumbar puncture 
offers a possibility of benefit. Various operative measures have been 
proposed. Communications have been established between the lateral 
ventricles and the subarachnoid space. A number of cases have been 
treated in this way. The dangers of the operation are considerable; 
nearly half of the patients have died as a direct result. Of those who 
have survived, a few have shown striking improvement, but no complete 
euro have been reported. 

Drainage into the jugular vein and into the subcutaneous tissues has 
also been employed. These operations offer but little possibility of cure. 



778 



DISEASES OF THE NERVOUS SYSTEM 



Eetrogression of the symptoms is not to be looked for. The most that 
can be hoped is to prevent any further injury to the brain. With the 
knowledge that has been recently acquired in regard to the cause of this 
disease, there is a much greater possibility of intelligently attacking the 
condition by surgical means. 

Cranial Deformities Associated with Hydrocephalus. — Various cra- 
nial deformities may at times be associated with a considerable de- 
gree of hydrocephalus. The two most frequent of these are oxyceph- 
aly ("steeple-head" or turmschadel) and scaphocephaly. In oxycephaly 
(Fig. 107) the head is very high and short; in scaphocephaly (Fig. 




Fig. 107. — Oxycephaly with Exoph- 
thalmus and partial blindness, 
with Optic Nerve Atrophy. 
Child 2 years old. 




Fig. 108. — Scaphocephaly; in infant 17 
months old. 



108), it is narrow and elongated from before backwards. In addition 
to the change in the shape of the head, there may be with either form 
some degree of exophthalmus and optic atrophy which causes impairment 
of vision. This varies in severity from slight interference with sight to 
complete blindness. The intelligence is usually quite normal. Smell is 
often completely lost. Taste very rarely is affected. These cranial de- 
formities seem to have no effect upon the duration of life. They are not 
amenable to treatment and the optic atrophy is usually progressive. It 
is possible that cerebral decompression may retard the optic changes but 
this has not yet been sufficiently employed to warrant a conclusion as to 
its influence. 



INFANTILE CEREBRAL PARALYSIS 



779 



INFANTILE CEREBRAL PARALYSIS 

(Spastic Diplegia, Paraplegia, or Hemiplegia) 

Under the term cerebral paralysis are included several groups of cases 
with causes quite dissimilar, but having certain definite clinical features 
in common. While the symptomatology is quite clear, there are many 
questions relating to the pathology that are not yet fully settled, al- 
though much has been added to our knowledge within the last few years. 
Paralysis depending upon cerebral tumor, abscess, or hydrocephalus is 
not included in this chapter. 




Fig. 109. — Extensive Atrophy and Sclerosis of the Right Hemisphere. From an 
infant seven and a half months old; probably the result of a meningeal hemorrhage 
at birth. History. — Twelve bours after birth was seized with general convulsions, 
which continued for three days. No other symptoms noticed till one month before 
death, when weakness of the left arm was observed. Never held head erect. Was 
plump and well nourished; died from erysipelas. Autopsy. — Pia not adherent; a 
large cyst occupied the region of the occipital and posterior part of the parietal lobes, 
showing in its floor discoloration and pigmentation, evidently from an old hemorrhage. 
Right optic nerve, tract, and crus much smaller than the left. 



The cases of cerebral paralysis may be divided into three groups, 
according as the paralysis depends upon conditions existing prior to 
birth, upon those connected with birth, or upon those of subsequent 
development. 

I. Paralysis of Intra-Uterine Origin. — This is the least frequent con- 
dition. In such cases there is some congenital defeci in the brain, due 
sometimes to arrest of development, at others to such intra-uterine lesions 
as hemorrhage or thrombosis. There may be porencephalus, or cysts 
extending deeply into the substance of the brain, sometimes communicat- 
ing with the ventricles. The origin of this condition is tor the most 
part unknown. In rare cases the paralysis is due to cortical agenesis, a 



780 DISEASES OF THE NERVOUS SYSTEM 

condition in which the brain may seem normal to the naked eye, but the 
microscope shows a more or less complete arrest in the development of 
the cells of the cortex, usually affecting both hemispheres. In still other 
cases there are found gross defects in development in the motor centers 
of the cortex. Such a lesion is shown in Fig. 114. Cases in which 
there is conclusive evidence of intra-uterine hemorrhage are very rare. 

In most of the paralyses due to intra-uterine lesions, loss of power is 
only one of the symptoms and usually not the most prominent. It is 
rare that there is not some mental impairment, and usually idiocy is 
present. The type of paralysis is nearly always diplegic or paraplegic. 
When this is due to arrested cortical development, a general flaccidity of 
the muscles may be seen instead of the rigidity so characteristic of the 
other forms of cerebral paralysis. 

II. Birth-Paralysis. — Cerebral birth-paralysis is due in nearly all 
cases to meningeal hemorrhage. The primary lesions and the early 
symptoms have already been described in connection with the Diseases of 
the Newly Born. The secondary lesions present considerable variety. 
There may be found (1) meningo-encephalitis, (2) atrophy and sclerosis 
of the cortex, (3) cysts upon the surface, (4) secondary degenerations in 
the spinal cord. 

1. Meningo-encephalitis. — This lesion is often quite diffuse. There 
is thickening of the pia mater, and it is usually adherent to the brain 
substance. The cortex is involved to a variable degree, depending some- 
what upon the time which elapses between the initial lesion and the 
autopsy. The following were the microscopical changes found in the 
brain of a child in the Babies' Hospital, who died at the age of one year 
of measles 1 : The lesions were found everywhere in the cortex. The 
pia was universally adherent, and showed general cellular infiltration; 
its blood-vessels showed marked cell proliferation, and the veins in the 
sub-pial space were dilated and filled with blood. In the pia dipping in 
between the convolutions similar changes were present. In the cortex 
few, if any, normal pyramidal cells were found, but in the outer layers 
were an enormous number of small glia cells. Many of the blood- 
vessels showed a cell-proliferation of their walls. There was also de- 
generation in the pyramidal tracts of the lateral columns of the cord. 

2. Atrophy and Sclerosis. — These changes vary much in extent and 
degree. There may be only a circumscribed area in which the convolu- 

1 The child was a first-born, delivered after a dry labor of forty-eight hours. 
He was asphyxiated, and from the first days of his life he had attacks of convul- 
sions, usually repeated many times a day. (Photographed during one of these 
attacks. Fig. 110.) The child had the symptoms of typical spastic paraplegia — 
the arms being, however, slightly involved — retarded mental development, and 
convergent strabismus. 



INFANTILE CEREBRAL PARALYSIS 



781 



tions are small, firmer than usual, and covered with an adherent pia, or 
there may be an atrophy so extensive as to involve a large part of one 
hemisphere (Fig. 109), or sometimes of both hemispheres. Usually the 
lesion is somewhat diffuse over the convexity of both sides, and much 
more frequently of the anterior than of the posterior half of the brain. 
Where a depression of the brain exists the space is filled with cerebro- 
spinal fluid, and in many cases there is a deformity of the skull. 

3. Cysts upon the surface may occur alone or in connection with the 
lesions just mentioned. These are usually small, about the size of a 
walnut, but they may cover a large part of a hemisphere. Such large 
cysts are sometimes classed as cases of external hydrocephalus. 




Fig. 110. — Convulsions in Spastic Paraplegia. 



•4. Secondary degenerations of the internal capsule and the lateral 
columns of the cord are found in most of the cases associated with ex- 
tensive atrophy and sclerosis, and in many of those in which only men- 
ingo-encephalitis is present. 

Symptoms. — The type of paralysis will, of course, depend upon the 
extent and position of the original lesion. A diffuse lesion is followed 
by diplegia; one not quite so extensive by paraplegia; one affecting one 
side only, by hemiplegia, or even monoplegia, though this is very rare. 
The relative frequency of the different forms will vary according to the 
age at which the patients come under observation. According io out 
observations, which have been chiefly upon infants, the cases of diplegia 
and paraplegia have outnumbered those of hemiplegia more than four 
to one. The great majority of the congenita] cases, or those due t" 
hemorrhage occurring at birth, are without doubl diplegias or para- 
plegias, and very many of them succumb during the firsl two years; 
however, the cases of hemiplegia, because of tin- less serious lesion, live 
much longer. Diplegia and paraplegia will then Pore be considered as 



782 



DISEASES OF THE NERVOUS SYSTEM 



the characteristic types of cerebral birth-palsy, as the cases of hemiplegia 
do not differ from those due to later causes — i. e., the acquired form. 

In the most severe cases that survive the symptoms of the early days 
of life there remains some rigidity of the extremities, chiefly of the legs, 

which is constant or intermittent, slight 
or well marked. There is often spasm 
of the muscles of the neck and trunk, 
giving rise to opisthotonus. In many 
cases there are frequent attacks of con- 
vulsions. The general physical develop- 
ment of the child is often interfered 
with, so that he remians small and del- 
icate, or perhaps dies of some acute dis- 
ease in early infancy, never having been 
able to sit erect, or even support his 
head. In other cases the general nutri- 
tion is not affected, and life may be pro- 
longed indefinitely, but usually with 
some mental impairment. This is seen 
in all degrees ; it may be so slight as not 
to be noticed until the child is two or 
three years old, or the child may be 
idiotic. Often these children are not 
able to stand until they are over three 
years old and do not walk alone until 
they are four or five years old, and then 
with a peculiar cross-legged gait, owing 
to spasm of the adductors of the thighs. 
This may be so great as entirely to pre- 
vent walking, and while sitting or lying 
the thighs may cross each other. These 
form the typical cases of spastic para- 
plegia, sometimes called "Little's dis- 
ease" (Fig. 111). All the reflexes are 
greatly exaggerated. The arms are 
much less affected than the legs, and in about half the number they are 
not involved at all. 

In the milder cases the early symptoms may be overlooked, and noth- 
ing excite suspicion until the infant is six or eight months old. There 
is then discovered unmistakable muscular weakness; the child does not 
sit up, or even hold up the head when the trunk is supported. Often 
there is observed before this time a tendency to stiffen the body and to 
throw the head backward, owing to spasm of the cervical or spinal mus- 




Fig. 111. — Spastic Paraplegia, 
Child two and one-half years old. 
New York Foundling Hospital, 
unable to walk or even to stand 
without assistance. The habitual 
position of the limbs, which is due 
to strong adductor spasm, is 
shown in the picture. 



INFANTILE CEREBRAL PARALYSIS 783 

cles. The muscular weakness is often mistaken for rickets, or regarded 
simply as backwardness. A closer examination usually discloses the pres- 
ence of some rigidity of the extremities, particularly of the legs, and 
exaggeration of the knee-jerks. As the child grows older other symp- 
toms of imperfect development become more and more evident. 

There are changes in the shape of the skull, this being usually smaller 
than normal in all its diameters, or there may be asymmetry. There is 
an arrest of development in the paralyzed limbs. These are both smaller 
and shorter than normal. In many cases abnormal movements are seen, 
which may be of an irregular choreic type, or they may be athetoid. 
Epilepsy develops in from thirty-three to fifty per cent of all these 
patients. 

III. Acute Acquired Paralysis. — This is usually of the hemiplegic 
type, although diplegia and paraplegia may in rare instances be met 
with. This group includes cases developing at any time after birth, but 
the great majority of those seen in childhood begin before the fifth 
year. 

The etiology is often obscure. The paralysis sometimes follows 
traumatism. It is occasionally seen in the course of scarlet fever, 
measles, diphtheria, variola, pneumonia, or pertussis. The frequency 
with which these cases are ushered in with convulsions has led many 
to assign this as the cause of the paralysis. It is probable that the convul- 
sions are more often the result than the cause of the lesion. In the acute 
inflammatory cases the cause is probably the same as in acute polio- 
myelitis. 

Lesions. — The lesions of acute cerebral palsy may be grouped under 
three heads: (1) those of the blood-vessels: (2) those of the membranes; 
(3) those of the brain substance. 

1. Lesions of the Blood-vessels. — There may be hemorrhage, em- 
bolism, or thrombosis. Hemorrhage is by far the most important. It is 
usually meningeal, rarely cerebral. It occurs more frequently at the con- 
vexity than at the base, and is often diffuse. Meningeal hemorrhage 
may result from pachymeningitis. It may be due to traumatism, when 
it is also from the dura mater ; or from the acute hyperemia accompany- 
ing paroxysms of pertussis, when it may be from the dura or the pia; 
or it may be secondary to thrombosis of the superior longitudinal sinus. 
The association of hemorrhage with sinus-thrombosis is not very in- 
frequent. It was found in two of our autopsies upon patients who died 
of pneumonia. Cerebral hemorrhage is extremely rare, but it occurs 
even in young infants. 

Embolism is rarely found unless associated with acute rheumatic 
endocarditis, and then usually in children who are over seven years 
old. As in adults, the usual seat of the embolus is a branch of the 



784 



DISEASES OF THE NERVOUS SYSTEM 



middle cerebral artery. Thrombosis has been met with in a small num- 
ber of eases, but is extremely rare. 

2. Lesions of the Membranes. — These are generally the result of 
an old cerebrospinal meningitis; sometimes they may be of syphilitic 
origin. In both, however, the process is rarely confined to the mem- 
branes ; it is a meningoencephalitis. 

3. Lesions of the Brain Substance. — Atrophy and sclerosis are found 
in a large number of the autopsies made upon cases when the paralysis 

has been of long standing. 
They represent terminal 
conditions, however. They 
vary in severity and extent, 
and are followed by secon- 
dary degeneration in the 
cord, as in cases of birth 
paralysis. There may be 
the same development of 
cysts of the pia mater, or an 
accumulation of fluid in the 
arachnoid cavity, these tak- 
ing the place of the atro- 
phied convolutions. The 
nature of the primary lesion 
in these cases is not always 
clear. In a certain number 
of them it is an acute poli- 
encephalitis, analogous to 
acute poliomyelitis, and 
probably due to the same 
cause. The cerebral lesion 
may be associated with cord 
lesions or it may occur alone. Their nature is considered in the chapter 
on Poliomyelitis. In still other cases a chronic diffuse encephalitis with 
atrophy is found at autopsy, closely resembling the conditions which 
follow a meningeal hemorrhage occurring at birth, yet the children 
were normal up to the second or third year, and there was no acute 
onset. 

Acute paralysis sometimes occurs for which no explanation can be 
found at autopsy. An infant with pneumonia was admitted to the 
Babies' Hospital, who had developed, a few days before, typical right 
hemiplegia. It came on suddenly, with convulsions, and involved the 
face, arm, and leg. The arm and leg appeared to be completely para- 
lyzed, but in the face the paralysis was incomplete. The paralysis 




Fig. 112. — Recent Meningeal Hemorrhage. 
Brain of an infant seven months old in the 
Babies' Hospital. A, punctate hemorrhages; 
B, thrombosed vessels; C, diffuse extravasa- 
tion. 



INFANTILE CEREBRAL PARALYSIS 785 

had begun to improve somewhat at the time of the child's death, 
which occurred a little over a week after the onset. At the autopsy 
no gross lesion could be discovered. A careful microscopical exam- 
ination was made, and nothing abnormal was found except a slight 
increase of small spheroidal cells about some of the meningeal and 
cortical vessels of the motor area. Such cases are most likely a cerebral 
form of poliomyelitis. 

Symptoms. — While diplegia and paraplegia are occasionally seen, 
the great majority of cases of acquired cerebral palsy are of the hemi- 
plegic variety. When diplegia and paraplegia occur, it is usually in 
early infancy, and their symptoms and course differ in no wise from the 
birth palsies. We may therefore regard hemiplegia as the chief mani- 
festation of acquired cerebral palsy. 

The onset of the paralysis is almost invariably acute, with convul- 
sions, which are usually repeated, and in severe cases followed by loss of 
consciousness. In the secondary cases these are generally the only symp- 
toms. In one of our cases the patient went to bed apparently well, and 
awoke in the morning with hemiplegia. Such an onset, however, is very 
exceptional. 

When the paralysis is due to acute poliencephalitis, the onset is usu- 
ally with high fever, vomiting, often convulsions, followed by delirium 
or stupor. These general symptoms continue for a variable time, usually 
two or three days, before paralysis is seen. The temperature in most 
cases is from 101° to 103° F., and the fever sometimes follows, sometimes 
precedes, the convulsions. The loss of consciousness may last for several 
days, and the paralysis is frequently not discovered until consciousness 
is regained. If there is a very extensive lesion there may be diplegia, 
deep coma, and death, but this is very infrequent. Usually the lesion is 
more limited, and the symptoms are those of typical hemiplegia. The 
face sometimes escapes, and if involved it generally soon recovers. The 
paralysis of the arm and leg is at first complete, but may improve rap- 
idly in the course of a few weeks. Disturbances of sensation may be 
present, but are usually of a transient character. After a variable 
period, from one to several weeks, the patient begins to use the paralyzed 
extremities, first the leg, afterward the arm, as in adult hemiplegia. 
The convulsions may be repeated for the first day or two, but prolonged 
or continuous convulsions are rare. They may be general or unilateral. 
With lesions of the left side of the brain, speech may be affected, and 
not infrequently in young children when the lesion is upon the right 
side. 'Idle reflexes are increased upon the affected side, and a slighl 
ankle-clonus may be present. 

After a few weeks the child may be aide to walk, dragging the af- 
fected leg. The recovery in the leg is sometimes complete, bul in most 



786 



DISEASES OF THE NERVOUS SYSTEM 



cases a slight halt in the gait remains. The arm usually recovers more 
slowly than the leg, and contractures are likely to develop after a variable 
time, generally two or three years. In Fig. 113 is shown a characteris- 
tic deformity of the upper extremity. Contractures of the leg lead to 
various forms of talipes, generally equinus, from shortening of the tendo- 

Achillis. Sometimes the arm or the leg 
recovers so perfectly that the case may 
be regarded as one of monoplegia. In 
old cases the paralyzed limbs are atro- 
phied ; there is more or less rigidity, and 
the spastic condition may be quite 
marked. We have seen this limited to 
a single group of muscles in the leg. 
Aphasia is common in right hemi- 
plegias, and it is not very rare in those 
of the left side, because infants appear 
to use both sides of the brain with nearly 
equal facility. 

The mental condition of these chil- 
dren is often normal, in striking con- 
trast with the cases of congenital di- 
plegia. The earlier the paralysis occurs 
the more likely are mental symptoms to 
be present, since we have here not only 
the direct effect of the lesion, but an 
arrested development of some part of 
the brain. Epilepsy is not an uncom- 
mon sequel ; it may be of the Jacksonian 
type, or there may be attacks of general 
convulsions. In other cases there are 
post-hemiplegic movements of a choreic 
or athetoid character, or irregular inco- 
ordinate movements. 

Prognosis of Infantile Cerebral Pa- 
ralysis. — In diplegia and paraplegia the 
outlook is always unfavorable. A very large number of these cases which 
are due either to intra-uterine or birth lesions never reach the third year, 
but die in infancy from malnutrition or acute intercurrent disease. 
Those who survive usually show serious mental defects, and many are 
practically helpless on account of the extreme spastic condition of the 
muscles of the extremities. 

In hemiplegia the prognosis is much more favorable. In most of 
these cases the paralysis is of the acute acquired variety, and the later 




Fig. 113. — Deformity of Left 
Hand the Result of Contrac- 
tures Following an Attack of 
Hemiplegia Four Years Be- 
fore. Child seven years old. 



INFANTILE CEREBRAL PARALYSIS 787 

the period of onset, the less likely is the brain to be seriously damaged. 
In some of these patients complete recovery takes place; in others the 
residual paralysis is so slight as to be easily overlooked except on careful 
examination, the occurrence of epilepsy being perha]3s the first thing 
which leads one to suspect that a previous paralysis has existed. The 
great majority of children who have suffered from infantile cerebral 
palsy have some degree of permanent paralysis and usually some deformi- 
ties from contractures, the extent of both varying, of course, with the 
severity of the primary lesion. In all cases seen in young infants it is 
exceedingly difficult to give a prognosis in regard to future mental de- 
velopment. As a rule, the impairment is directly proportionate to the 
extent of the paralysis and its intensity. 

Diagnosis. — The diagnosis between the congenital and acquired 
forms of cerebral palsy is of no great practical importance, and it may 
be impossible; for the symptoms in congenital cases are often not suffi- 
ciently marked to attract attention until children are old enough to sit 
alone or to walk. 

It may be quite difficult to distinguish cerebral paralysis from infan- 
tile spinal paralysis. The history of an acute onset, the atrophied limbs, 
the deformities, and the absence of sensory disturbances, may be found 
in both conditions. Spinal paralysis is, as a rule, monoplegic. and often 
affects but a single group of muscles. Cerebral paralysis is either di- 
plegic or hemiplegic in character, and even though only a leg or an arm 
may seem to be affected, a critical examination will usually reveal the 
fact that the other limb of the same side has also suffered. The presence 
of rigidity and exaggerated reflexes is quite as important evidence of 
this as loss of power. The electrical reactions, however, are usually con- 
clusive ; the reaction of degeneration is absent in cerebral paralysis, while 
it is usually present in spinal paralysis. 

Simple as the differentiation may seem in most cases, the mistake is 
frequently made of confounding cerebral diplegia, particularly of the 
flaccid type, with rickets. Cases of acute acquired paralysis at the onset 
may be mistaken for acute meningitis, but early loss of consciousness, 
the early development of the paralysis, its permanent character, and the 
shorter duration of the acute symptoms, usually distinguish these i 
from those of meningitis. The only definite means of differential diag- 
nosis is by lumbar puncture; this gives negative results in cerebral paral- 
ysis and positive results in meningitis. 

Treatment. — The course and the results of cerebral paralysis depend 
upon the extent of the injury to the brain, its nature, and the age at 
Which it is inflicted — all these being conditions which are beyond the 
power of the physician to modify or control. The treatment of cerebral 
palsy is therefore extremely unsatisfactory. For the congenita] cas< 



788 DISEASES OF THE NERVOUS SYSTEM 

practically nothing can be done, except for the deformities and compli- 
cations. The acquired cases during the acute onset are to be managed 
like all other cases of acute cerebral congestion or inflammation — abso- 
lute rest, ice to the head, and bromids. Electricity is not to be used 
in early cases, and little or nothing is to be expected from it in the late 
ones. Much can be accomplished in an educational way for the mental 
derangements resulting from cerebral palsy. An important part of the 
treatment relates to the deformities. Many of these may be prevented 
by the early use of orthopedic apparatus. Serious deformities in old 
cases may be greatly benefited by tenotomy or myotomy, followed by 
the use of suitable apparatus. The results of all other operative meas- 
ures have been in our experience most unsatisfactory. Epilepsy is to be 
treated as when it depends on other causes. 



AMAUROTIC FAMILY IDIOCY 

Amaurotic family idiocy is a relatively rare disease. It is confined, 
almost, if not entirely, to the Jewish race. It shows strong familial 
tendencies — often two or three and sometimes even four or five children 
in the same family dying of the disease. There are no other known 
etiological influences. 

The first symptoms are usually noticed between the sixth and the 
tenth months, up to which time the infant has generally appeared 
normal. At first it is only noticed that the child is making no progress 
in his development, or that his eyesight is not so good as formerly. He 
does not gain in ability to sit up or to use his muscles; he lies quietly, 
does not respond as he once did, and takes less interest in his surround- 
ings. After a few weeks it is clear that the child, instead of advancing, 
is actually retrograding both physically and mentally. His muscles 
become so weak that he can no longer sit up or even hold up his 
head. Vision becomes less and less distinct; the child no longer recog- 
nizes the faces of friends or objects shown him. Finally, he becomes 
dull, apathetic and quite indifferent to his surroundings; then it is 
evident that he can not see at all. In the early stages the muscles 
are usually weak and flaccid; later there is rigidity with increased knee 
jerks and often marked spasticity. Children with amaurotic family 
idiocy are often fat and well nourished, but with the onset of weakness 
loss of weight occurs and eventually this may be so extreme that the 
emaciation may be a prominent factor. There may be general convul- 
sions. The characteristic features of the disease are revealed by the 
ophthalmoscope. Occupying the place of the macula lutea there is a 
large, milky blue or white area with a bright cherry-red spot in its 



MENTAL DEFICIENCY 789 

center. With this there is also atrophy of the optic discs. The ocular 
changes are symmetrical. 

The outlook is absolutely bad. The disease is progressive and 
usually fatal within a year from the time when the first symptoms are 
seen; but occasionally the blind, helpless child may live for several 
years if feeding with the stomach tube is resorted to, for swallowing 
eventually may become quite impossible. 

There are characteristic pathological changes to be found in the 
cells of the central nervous system. The brain itself is not diminished 
in size, but is more firm and elastic than normal. The same is true of 
the cord. Microscopically, the ganglion cells show a marked and striking 
degeneration. They are swollen, their protoplasm is undifferentiated 
and the nucleus is excentrically situated and degenerating. There are 
oftentimes large, ovoid swellings upon the cell processes. Ultimately 
the nerve cells disappear and are replaced by neuroglia. These changes 
are very wide-spread and are found in the retina as well as in the 
brain and cord. In many cases hardly a normal ganglion cell may 
be found. 

To be differentiated from amaurotic family idiocy is a less frequent 
form of degeneration, known as "familial maculo-cerebral degeneration." 
It attacks several children in a family and at about the age of six or 
seven years. These children become dull, stupid, lose their power of 
attention and eventually their ability to read, speak or even recognize 
people. With these symptoms there is a central scotoma which may be 
of high degree but does not produce complete blindness. The physical 
condition of the child may remain normal for a long time. The eyes 
show a combination of atrophy of the retina with pigmentation espe- 
cially in the region of the macula. The condition is incurable. It is 
progressive, though the patients may live many years. Death occurs 
from intercurrent infection rather than from the disease itself. 



MENTAL DEFICIENCY 

(Idiocy — Imbecility) 

By mental deficiency is meant any interference with Intelligence 
or a limitation in the adaptation of the child i<> his environment. This 
interference with intelligence may occur in children as the result of 

various general diseases or those confined to the nervous system. 
Tn other chapters the menial deficiency occurring secondary to general 

diseases and also to organic disease of the nervous system, such as hydro- 
cephalus, chronic meningitis, paresis, meningeal hemorrhage, etc., is 



790 DISEASES OF THE NERVOUS SYSTEM 

discussed. The present chapter will treat only of mental deficiency 
as an apparently primary condition. 

Of all the factors that operate to produce mental deficiency, heredity 
is the most important. This statement does not require substantiation. 
It is generally recognized. The descendants of mental defectives may 
be normal, they may be so defective that it is readily appreciable in the 
first year or two, or the disturbance of mentality may be so slight that 
it can be recognized only after several years of life. The influence 
of parental alcoholism, especially chronic alcoholism, has been much 
discussed and there is a wide difference of opinion in regard to it. 
Some claim that it plays a distinct part in the production of feeble- 
mindedness ; some, that it plays little or none. It seems to us that it is a 
factor of some importance. While it cannot be entirely ignored, it 
certainly does not have the influence that has been ascribed to it by 
many. Whether syphilitic infection per se tends to produce mental 
deficiency is open to question. It does not appear likely that its influence 
can be great unless it produces organic changes in the meninges or in 
the brain itself or in the blood vessels. Poverty, poor surroundings, 
bad atmosphere, etc., have been claimed to have an influence by affecting 
the health of the mother. Associated with these are almost always 
other factors such as heredity and alcoholism that probably have much 
more effect upon the offspring. 

The changes to be found in the brains of defectives are of all degrees 
of severity. (Fig. 114.) There may be an atrophy of one or more 
portions of the brain, failure of development of one hemisphere, poorly 
developed convolutions and shallow sulci. In certain cases no changes 
are to be made out macroscopically. The position can be well main- 
tained, however, that even in such cases, mental deficiency is dependent 
upon actual organic changes in the brain, for practically all observers 
have found, as did Hammaberg, that even when no gross alteration 
was apparent the ganglion cells were infrequent and poorly developed. . 

There may be all grades of mental deficiency. It is usual in this 
country to separate mentally defective children into three groups: (1) 
the idiots, those that never develop beyond the mental age of an average 
child of two years; (2) the imbeciles, those that never acquire a higher 
degree of mentality than the average child of seven, and (3) the morons, 
who do not acquire a higher degree of mentality than children of 
twelve. 

It is frequently necessary for the physician to determine whether or 
not a child is mentally deficient. In doing so it should be remembered 
that normal mental development is very dependent upon physical 
development; but it does not necessarily go on with equal rapidity. 
If an infant has been premature or badly nourished for many months or 



MENTAL DEFICIENCY 701 

has suffered from some very severe illness, he may at the end of a 
year show no more mental development than an average child of six or 
eight months. Yet, with improvement in his physical condition his 
mental condition also improves so that eventually the normal is reached. 
There is a wide variation in the rapidity of development of normal chil- 
dren. Some are quite slow, especially in certain families. Proper atten- 




Fig. 114. — Arrested Development of the Frontal Lobes of the Brain, Particu- 
larly of the Right Side. From an idiotic child twelve months old. 1 

tion should be paid to this fact and too much emphasis should nol be 
placed upon only slight deviations from the normal. The abnormal in- 
fant is distinguished not by slight, but by gross deviation from the 
normal. A high degree of mental deficiency can usually be recognized 
very early; the lesser degrees require longer observation. Even those 
children that are only slightly affected often give sonic definite evidence 
of it during infancy. Their menial developmenl begins late and usually 

1 Microscopical Examination: Cortex in affected region one-third normal 
thickness; membranes and white substance normal; striking absence of char- 
acteristic nerve cells; very few large or small pyramidal cells present. 



792 



DISEASES OF THE NERVOUS SYSTEM 



ends early. It is fair to assume that those whose mental development, in 
the absence of sufficient physical cause, is abnormally delayed, will suffer 
some permanent impairment of the mental faculties; but owing to the 
differences in the length of time that improvement may occur in differ- 
ent children, it is impossible to predict closely as to the final out- 



come. 



To appreciate the abnormal, one must be familiar with the mental 
and physical development of normal children. Mental development 
shows itself in the early months of life chiefly by the acquisition of the 
ability to do certain physical things. The normal child about the 
third month begins to grasp objects — at the fourth month he recognizes 
people, between the third and fifth months he holds his head up firmly, 
at the fifth month he reaches for things, holds them in his hands and 






^ . TJ«l—i.,» ._l fit., ^nmr i 

Fig. 115. Fig. 110. Fig. 117. 

Fig. 115. — Boy twelve years old; microcephalic; walked at about four years; can read 

and write; development like that of a normal child of eight years. 
Fig. 116. — Microcephalic, seven years old; understands most of what is said; cannot 

talk intelligibly. 
Fig. 117. — Girl of eight years; imbecile; cannot walk without help. 

observes them. From seven to nine months, he sits alone, and laughs 
in play. From nine to ten months, many children stand. At a year 
they often begin to walk and to repeat single words. The mentally 
deficient child, on the other hand, may not even hold his head up at the 
end of a year. He makes no attempt to grasp objects, perhaps holds 
them for only a moment and then drops them. He cannot sit alone, he 
does not attempt to stand, and does not recognize people until perhaps 
the end of the second year or very much later. 

Some mentally deficient children are exceedingly placid; others cry 
continually without apparent cause and are often exceedingly restless. 
The expression of the normal child is intelligent, bright and alert; the 
abnormal (Figs. 115, 116, 117) may betray his lack of mental capacity 
by his vacant, stupid expression, his open mouth, protruding tongue, 
drooling and his irregular, aimless movements of the hands. As time 
goes on, mentally deficient children not only remain backward in things 
that they should do, but they also do things that normal children do not 



MONGOLIAN IDIOCY 793 

do. They develop screaming attacks, they throw their heads backward or 
frequently stiffen out. Strabismus is often present and there may be ill- 
defined attacks of a convulsive nature or typical convulsions. 

It may be exceedingly difficult at times to differentiate between the 
merely backward child or the mentally deficient. The backward child 
is usually distinguished chiefly by the things which he does not do. 
He does not show an abnormal mentality. Children merely backward 
as the result of disease may not be able to talk until two years old or may 
not walk until after that time, yet may understand what is said and 
done for them; their expression is normal; they seem bright, and the 
development, although slow, is steady and progressive. Mentally defi- 
cient children, on the other hand, are not only very backward, but they 
usually reach the end of their development fairly early and it is not a 
complete development. As Scholz says, "the mentally deficient child of 
twelve is not a normal child of six; he is not merely a dwarf, but a 
cripple." This becomes increasingly evident as the defective child be- 
comes older and his character and mental processes find better expres- 
sion. He may be disobedient, unruly, untrustworthy, cruel to animals 
and playmates, not interested in the play of children, and may not 
conform to the ordinary standards of cleanliness and neatness. Most of 
the children are clumsy in their movements and especially not dextrous 
with their hands. There are many children, however, that are docile, 
kind and affectionate, but whose faculties are totally inadequate when 
compared with those of the average child. One with experience in testing 
mentally deficient children is able to tell with a considerable measure 
of accuracy what their mental capacity is. This is accomplished by 
observation and various tests, including the Binet-Simon test. This 
standardizing need not concern us here; but all physicians should be in 
a position to recognize the abnormal. The standardization of the abnor- 
mal and particularly the training should be in the hands of experts 
in that field. 

MONGOLIAN IDIOCY 

A form of mental deficiency that can be at once recognized by the 
physical characteristics of the child is the so-called Mongolian [diocy, 
also known as "Kalmuck Idiocy." The cause of this is obscure. It cannoi 
be shown that it is due in any way to syphilis or to the excessive use of 
alcohol in the parents. The condition appears with equal frequency in 
the sexes. It is found in the Caucasian race and we have seen several 
instances in the colored, hut it has apparently not been reported among 
the Malay or Mongolian races. The factor of greatesl importance is 
the age of the mother. The majority of Mongolian idiots are born to 



794 



DISEASES OF THE NERVOUS SYSTEM 



women over 35 years of age. The number of pregnancies also appears 
to have an influence. These children are not infrequently the last after 
the birth of a number of healthy children. Much less frequently, they 
are the first, but the number of first or last children that are Mongols 
is greatly in excess of those in the middle of families. It is evident that 
the reproductive function has an important bearing upon their develop- 
ment. They are probably the result of incomplete or inhibited develop- 
ment, and have been called by Shuttleworth "exhaustion products." 

This is one of the common forms of mental defect, apparently more 
frequent in England and in this country than elsewhere, perhaps on 

Mongolian Types 






Fig. 118. 



Fig. 119. 



Fig. 120. 



Fig. 118. — Six months old; died at twenty-two months; could not hold up the head, or 

understand anything. 
Fig. 119. — Boy, twenty-one months old; did not hold up his head until eighteen months; 

mental development that of a child of eleven or twelve months. 
Fig. 120. — Girl four years old; mental development like that of a normal child of two 

and a half years; walks very awkwardly. 



account of closer observation, as the result of the frequent attention that 
has been called to it. 

Pathologically, the brains are, as a rule, small. The convolutions 
are poorly developed and there is apt to be an aplasia of some parts, such 
as the cerebellum, pons or medulla. The cortex is frequently thin and 
the ganglion cells few in number, with rather scanty cell processes. 

The appearance of these children is very striking (Figs. 118, 119, 
120) and it can at once be seen whence they have derived their name. 
There is a peculiar Mongolian type of countenance; the eyes are set 
closely together, they are slanting and the palpebral fissures narrow. 
There is frequently epicanthus. The head is brachycephalic and small. 
At twelve months it is often two inches below the average in circumfer- 
ence. The- children are short for their age. Their hands are short and 
thick, especially the lingers; the little linger, not uncommonly, is so 
short that it docs not reach to the last interphalangeal joint of the ring 
finger. The muscles are poorly developed, and there is a great relaxa- 



DEAF-MUTISM 795 

tion of the ligaments, so that the strangest and most uncomfortable posi- 
tions can be assumed at will and often by preference. The tongue is 
usually prominent, slightly protruding and deeply fissured. There is 
usually drooling from the mouth and often a nasal discharge, so that 
the lips may be greatly excoriated. Mouth-breathing is nearly always 
present. The nasopharynx is often small, sometimes owing to back- 
ward projection of the vomer, sometimes to a forward projection of 
the bodies of the cervical vertebrae. A very moderate amount of adenoid 
tissue may produce marked symptoms of nasal obstruction. The expres- 
sion is often that of a child suffering from very large adenoid growths, 
and sometimes the early cases are passed over as simply "adenoids with 
mental dulness." Other defects are often associated. The ears are fre- 
quently misshapen; congenital malformations of the heart are quite 
common; in one of our cases there was absence of the patella. 

Mongolian idiots are very backward in development. They fre- 
quently do not hold up their heads until a year of age, or later, and may 
not walk until the end of the second or third year. Speech is greatly 
delayed and seldom normal; although almost all, if they live sufficiently 
long, do eventually talk to a certain extent. These children have but lit- 
tle resistance to any acute disease. They are particularly susceptible to 
infection, and the majority die in infancy or early childhood. We see 
many of them as infants and few after the eighth or tenth year. They 
succumb chiefly to pulmonary infections or to tuberculosis. There is a 
certain degree of variation in their mental capacity, but it is singularly 
slight, and, as the majority of them look much alike, so also their mental 
processes are alike, and very few of them reach a higher mental develop- 
ment than that represented by a normal child of four or five years. 
They are restless, inattentive, and can be taught with great difficulty. 



DEAF-MUTISM 

Excluding the cases in which idiocy is present, which are not con- 
sidered in this chapter, deaf-mutism may be due either to congenita] or 
acquired conditions; the larger proportion of the cases belong in the lat- 
ter class. When congenital, deaf-mutism may resull from ostitis, or 
periostitis of the temporal hone, encroaching upon the cavity of the 
middle ear, from ankylosis of the ossicles, from absence of the internal 
ear or any of its parts. There may also he colloid degeneration of fche 
labyrinth. It may result from atrophy of the auditory nerve, and it 
may he due to a lesion of the brain. These congenital conditions are 
often hereditary. An unusual form of congenital deafness is occasionally 
present with goiter. It is found especially in those regions in which 



796 DISEASES OF THE NERVOUS SYSTEM 

goiter is endemic. Its cause is unknown. Acquired deaf-mutism is most 
frequently the result of scarlet fever, and is due to otitis. The second 
important cause is cerebrospinal meningitis, where it may be due to a 
lesion of the brain, the auditory nerve, or the ear. It occasionally follows 
mumps, diphtheria, measles, and other infectious diseases. It may result 
from repeated attacks of acute otitis associated with adenoid growths or 
chronic rhinopharyngitis. 

The younger the child at the time the deafness occurs the sooner the 
power of speech is lost. In most of the infectious diseases, if the attack 
occurs before the fifth year, speech is lost. According to Love, total deaf- 
ness is rare among deaf-mutes; hearing for speech is present to a useful 
degree in about twenty-five per cent of the cases, while hearing by cranial 
conduction exists in nearly all cases. Deaf -mutism should be suspected 
if a child not idiotic shows at the end of two years no signs of beginning 
to talk. A careful distinction should be made between deaf-mutism 
and idiocy resulting either from congenital conditions or acquired dis- 
ease. 

It is necessary that this condition be recognized as early as possible, 
in order that the child may have the advantages of proper training 
during his early years. The physician should insist upon the child being 
sent as early as the third, and certainly by the fourth year to an institu- 
tion where he may be taught to speak. 

The treatment is mainly prophylactic. The most important relates 
to the care of the ears in scarlet fever, and the removal of adenoid vegeta- 
tions of the pharynx and other causes which produce attacks of acute or 
chronic otitis. For the condition itself education is the only thing to 
be considered. 



CHAPTER IV 

DISEASES OF THE SPINAL CORD 
MALFORMATIONS 

Malformations of the cord are very frequently associated with those 
of the brain, and bear a certain degree of resemblance to them. (1) 
The cord may be absent (amyelia) ; this condition may exist alone or 
with absence of the brain. (2) The lack of development may be only 
partial (atelomyelia), as when some of the tracts are wanting. The 
most important one is defective development of the lateral tracts, which 
may be a cause of spastic paraplegia (Charcot). (3) There may be a 
malposition of some of the gray matter (heterotopia). (4) There may 




MALFORMATIONS 797 

be a double cord (diplomyelia) ; the division is generally incomplete, 
and is attributed to an abnormal development of the central canal ; it is 
usually associated with other deformities. All of these malformations 
are extremely rare and of very little practical interest. 

There remains to be mentioned the only one which is really impor- 
tant — spina bifida. 

Spina Bifida. — This is a malformation of the vertebral canal with a 
protrusion of some part of its contents in the form of a fluid tumor. 
The tumor is elastic, compressible, usually increased by crying, and 
sometimes by pressure upon the anterior fontanel. The contained fluid 
is clear, resembling in all respects the cerebrospinal fluid. It is one of 
the most frequent congenital deformities. 

Spina bifida is due to an early failure in 
development — in most cases before the cord is 
segmentated from the epiblastic layer from 
which it is developed. Hence it remains ad- 
herent to the epiblastic covering, and the struc- 
tures which should be formed between the cord 
and the skin are undeveloped. For this reason 
there is in the wall of the sac a fusion of the XJ%iiZ—™. 
elements of the cord, nerves, meninges, verte- A, the membranes; B, 
bral arches, muscles, and integument. If the Jntei^ent^^The tc- 
error in development occurs later, the cord and cumulation of fluid is be- 

i i t , ,, iij_- hind the cord, which does 

nerves may be attached to the sac, but not m- not enter the sac 
timately fused with it; in still other cases the 

cord does not enter the sac at all. The malformation may occur before 
the central canal is closed; or, if closed, it may reopen from the ac- 
cumulation of fluid. It is probable that the accumulation of fluid first 
occurs, and that this prevents the union of the parts of the vertebral 
arches. 

Although the tumor is generally associated with a bifid spine, this 
is not necessarily the case. The protrusion may take place through the 
intervertebral notch or foramen, or there may be a fissure of the bodies 
of the vertebrae, and an anterior tumor projecting into the cavity of the 
thorax, abdomen, or pelvis ; the tumor may be so small as not to be recog- 
nized externally — spina bifida occulta. The principal anatomical varie- 
ties are meningocele, meningomyelocele, and syringomyelocele. 

Meningocele. — In this form there is a protrusion of the membranes 
only (Fig. 121). The accumulation of fluid is either in the arachnoid 
cavity or the subarachnoid space posterior to the cord. The opening of 
communication between the tumor and the spina] canal is small in this 
variety, usually being about one-twelfth to one-sixth of an inch in diam- 
eter. There may, however, be no communication. The skin is usually 
27 



798 



DISEASES OF THE NERVOUS SYSTEM 




fully developed (Fig. 122). The tumor is frequently globular, some- 
times pedunculated, and may attain a very large size, being as much as 

five or six inches in diameter. This 
is because spontaneous rupture is 
not likely to occur, and the tumor 
does not become infected except by 
operative interference. With such 
tumors patients may live to adult 
life. This variety is most frequent- 
ly seen in the cervical region. It has 
the best chance of natural recovery, 
and in it operation gives the best re- 
sults. 

Meningomyelocele. — This is by 
far the most frequent variety of 
spina bifida. It is the form usually 
seen in the sacrolumbar region. 
The accumulation of fluid takes 
place in the anterior subarachnoid 
space, less frequently in the anterior 
arachnoid cavity (Fig. 123). In 
this form the cord is contained in 
the sac, and usually forms a part of 
its wall. The tumor is smaller than the meningocele, the usual size being 
that of a mandarin orange. It is sessile, never pedunculated. As a rule 
it is only partly covered by skin, but has a central area, usually elliptical 
in shape, where there is only a 
thin, translucent membrane. This 
surface, which is known as the cen- 
tral cicatrix, is sometimes covered 
with granulations, and frequently 
ulcerates. The tumor often has a 
vertical furrow or a central umbil- 
ication, corresponding to the at- 
tachment of the cord on its inner 
surface. The usual relation of the 
parts is for the cord to run hori- 
zontally across the upper part of 
the tumor to the central cicatrix, 
with which it becomes blended, and 

from which again the nerves arise. These re-enter the canal at the lower 
part of the tumor, and are distributed below as usual. In other cases the 
cord joins the wall of the sac soon after its entrance, and its attenuated 



Fig. 122. — Meningocele, in a Child 
One Year Old. 




Fig. 123. — Meningomyelocele (partially 
diagrammatic). A, the membranes; 
B, the cord; C, the integument. The 
accumulation of fluid is in front of the 
cord, the filaments of which are spread 
out, forming a part of the wall of the 
sac. 



SPINA BIFIDA 799 

fibers are found spread out all over the sac, coming together again below 
and entering the spinal canal. 

The following case, upon which an autopsy was made, is a good ex- 
ample of the common variety : The child died on the third day after birth 
from rupture of the sac. The tumor occupied the sacral region. The 
first sacral vertebra was normal, and beneath this the cord passed out of 
the spinal canal, terminating in the cauda equina soon after entering the 
sac, and continued back to the central cicatrix. Here nerve filaments 
blended with the other tissues in an indefinite structure, from which 
again, with tolerable distinctness, the nerve structures could be seen to 
pass over the wall of the sac and return to the canal. The afferent and 
efferent nerves and the part of the membranes they carried with them 
formed several septa, making a smaller separate sac within the larger 
one. The large sac was clearly a dilatation of the anterior subarach- 
noid space, and communicated freely with the same space in the cord 
above. 

Syringomyelocele. — In this variety the accumulation of fluid is in 
the central canal of the cord, the lining of the sac being here the at- 
tenuated and atrophied cord elements. This is the rarest form of 
tumor, but the one most frequently associated with hydrocephalus, and 
consequently has the worst prognosis. It may be found in the dorsal 
or dorsolumbar region as well as in the lumbosacral. 

With spina bifida other deformities are frequently associated, the 
most common being club-foot, hydrocephalus, more rarely encephalo- 
cele or cerebral meningocele, and hare-lip. If hydrocephalus exists, 
there is in most cases a dilatation of the central canal of the cord and 
a direct communication between the tumor and the lateral ventricles of 
the brain. Pressure upon the anterior fontanel causes an increase in 
the size of the tumor, and conversely. Club-foot is usually double, most 
frequently talipes equino varus. In a number of cases there is a history 
of some deformity in other members of the family. We have seen two 
successive children in the same family with spina bifida. 

Symptoms. — The tumor in spina bifida is present at birth, and is 
most frequently lumbosacral. Paralysis is frequent in myelocele and 
syringomyelocele, but is not seen in meningocele; its degree and its 
location depend upon the situation of the tumor and the extent to 
which the cord is involved. It is rare in cervical tumors, and most 
marked in those situated in the lumbosacral region. In the worst 
cases there is complete paraplegia, with paralysis of the bladder and 
rectum. If the tumor is sacrolumbal' or sacral, only the cauda equina 
is likely to be involved, and this but partially, so thai the paralysis 
of the extremities is incomplete, and the bladder and rectum may 
escape. Spina bifida occulta is in rare instances the explanation of obsti- 



800 



DISEASES OF THE NERVOUS SYSTEM 



nate incontinence of urine and sometimes of feces also. It may occur 
without paraplegia. 

In Fig. 124 is shown a very remarkable case of sacral spina bifida 
in a boy of five years, who came under observation for incontinence of 
feces. The tumor was a little more to the left than to the right side, 
and had been overlooked. It had evidently pressed upon the lower 
branches of the sacral plexus, so as to affect the sphincter and the gluteal 
muscles of the left side. The atrophy was very marked, as shown in the 

illustration. 

The natural course of spina 
bifida is to increase steadily in 
size ; and if the tumor is covered 
by skin, its growth may be almost 
unlimited. It has been known to 
attain a circumference of twenty- 
two inches. If the integument is 
wanting, and the sac wall is very 
thin, rupture is pretty certain to 
take place, either spontaneously 
or by some accident, in the course 
of the first few months; usually 
death then results from convul- 
sions owing to the rapid draining 
away of the cerebrospinal fluid, or 
from infection. In a large num- 
ber of cases death is due to maras- 
mus dependent upon the asso- 
ciated conditions. Infection of 
the tumor may take place without 
rupture, the germs passing through the wall of the sac. If the opening 
communicating with the spinal canal is small, this infection may excite 
an inflammation limited to the wall of the sac, and result in a cure of 
the spina bifida, usually with sloughing. We have seen such a case in a 
girl ten years old in whom this occurred in infancy. The site of the 
former tumor was marked by a large dense cicatrix, and there still re- 
mained partial paralysis of the legs. If the opening into the spinal 
canal is large, inflammation of the sac is usually followed by spinal 
meningitis, which may extend upward and involve also the meninges of 
the brain. 

Prognosis. — This depends chiefly upon the anatomical variety and 
the existence of complications. Simple meningocele, when covered by 
integument, gives the best prognosis, and complete recovery may occur. 
In meningomyelocele, especially if complete paralysis exists, the prog- 




Fig. 124. — Sacral Spina Bifida. 



SPINA BIFIDA 801 

nosis is bad ; and if there is also hydrocephalus, the case is hopeless. In 
many cases in which cure of the spina bifida has followed operation, 
hydrocephalus has subsequently developed. Of fifty-seven cases reported 
by Demme, twenty-five were operated upon, with seven recoveries and 
fifteen deaths, while three were unimproved; of the thirty-two cases not 
operated upon, twenty-eight died within the first month, and not one 
lived over two years — the causes of death being marasmus, rupture of 
the sac, and meningitis. 

Diagnosis. — It is usually easy to recognize spina bifida, but it is often 
difficult to distinguish between the different varieties. The absence of 
a palpable fissure in the spine, perfect translucency, and a pedunculated 
tumor, all point strongly to meningocele. Paralysis of the sphincters 
and lower extremities, umbilication of the center of the tumor, a sessile 
tumor, a palpable bony fissure, and a large central cicatrix, point to 
meningomyelocele. The coexistence of hydrocephalus points to syringo- 
myelocele. 

Treatment. — In all cases the tumor should be protected from pres- 
sure, and when it is not covered by integument, care taken that the sur- 
face is kept absolutely clean and aseptic. It should be covered with 
some antiseptic powder and surrounded by a large pad of absorbent cot- 
ton, or a rubber ring-cushion. Complete paraplegia with involvement of 
the bladder and rectum, hydrocephalus, or extreme marasmus — all con- 
traindicate operative interference. If these are absent, operation should 
be considered. The time of operation will depend somewhat upon the 
nature of the tumor. If it is covered by integument and growing 
slowly, it is well to wait until the child is at least six months old. In 
other cases delay is dangerous, because of the liability to spontaneous or 
accidental rupture. 

The treatment by injection has now been entirely superseded by the 
operation of excision of the sac. For a description of this and the 
various plastic operations that have been proposed in connection with 
it the reader is referred to works upon operative surgery. In operating, 
it should not be forgotten that in the great proportion of the cases (nine- 
ty-five per cent, according to the London Clinical Society's Report, 
which, however, refers only to fatal cases) some part of the cord is in 
the sac. The cord is often present in tumors situated below the third 
lumbar vertebra, owing to its attachment to the sac. 

Although recovery may follow operation, in a very large number of 
cases it is incomplete; some degree of paralysis, with atrophy, contrac- 
tures and deformities, remaining because of the implication of cord ele- 
ments in the sac. In a considerable proportion of cases, hydrocephalus 
subsequently develops, as after similar operations upon cerebral menin- 
gocele. 



802 DISEASES OF THE NERVOUS SYSTEM 



SPINAL MENINGITIS 

In acute meningitis usually only the pia mater is involved. This 
rarely occurs alone, unless it is due to traumatism. It is most frequently 
associated with inflammation of the pia of the brain, and may occur 
either with the meningococcus or the tuberculous variety. A certain 
amount of acute inflammation of the pia mater accompanies most of the 
cases of acute myelitis. 

Chronic spinal meningitis in children usually involves the dura only. 
Inflammation of the external layer (external pachymeningitis) is usually 
secondar}^ to caries of the vertebrae. This is considered in the article on 
Compression-Myelitis. 

Symptoms. — The symptoms of inflammation of the spinal mem- 
branes, no matter with what pathological condition it may be associated, 
are due to irritation of, or pressure upon, the cord or nerve roots. Those 
which are most common are: pain in the back, which is increased by 
movement, and usually by pressure upon the spinous processes ; radiating 
pains following the course of the spinal nerves, felt in the extremities or 
in the trunk; rigidity of the spinal column due to spasm of the spinal 
muscles, or rigidity of the muscles of the extremities ; and hyperesthesia 
along the spine, which may be quite acute. When pressure upon the 
cord is added, there is paralysis or paresis, sometimes muscular atrophy 
and anesthesia. Any of the above symptoms may be acute or chronic, 
according to the nature of the primary disease. 

The diagnosis between spinal meningitis and myelitis is often not 
easy, for except in acute cases the two processes are usually associated; 
and in a given case it may be difficult to decide whether the lesion of the 
cord or of the membranes is the more important one. In meningitis, 
pain, tenderness, spasm, and irritative symptoms are generally more 
prominent, while loss of power and anesthesia are usually partial. In 
myelitis the pain, tenderness, and other irritative symptoms are less 
marked, while paralysis and anesthesia may be complete. 

Treatment. — This relates first to the disease with which it is asso- 
ciated ; in addition, counter-irritation by means of the Paquelin cautery, 
rest in bed, and in severe cases even immobilization of the spine by a 
mechanical support. Iodid of potassium is often useful. 



MYELITIS 

Myelitis is a rare disease in children, with the exception of two vari- 
eties which are discussed under separate heads, viz., compression-myelitis 



MYELITIS 803 

and acute poliomyelitis. Otherwise myelitis usually results from injury, 
but it may occur as a complication of any of the acute infectious dis- 
eases, especially typhoid, scarlet fever, and diphtheria, and even as a 
primary disease, when it is attributed to exposure or cold, but when it 
is probably of infectious origin. We have seen it follow varicella. 
Chronic myelitis may be due to hereditary syphilis. 

Myelitis usually occurs in children over ten years of age. In situa- 
tion, it may be transverse, diffuse, or disseminated; the process may be 
acute, subacute, or chronic. The lesions and the symptoms are essen- 
tially the same as when the disease occurs in the adult. 

Symptoms. — Myelitis usually comes on rather gradually, with only 
local symptoms; but the onset may be quite acute, with several general 
symptoms — fever, pain, prostration, and localized or general convulsions. 
The local symptoms vary with the seat and the extent of the disease. 

In transverse myelitis loss of power and anesthesia are present below 
the level of the lesion ; either of these may be partial or complete. At the 
level of the lesion there is a zone of hyperesthesia and "girdle-pains." 
All the reflexes below the seat of the lesion are exaggerated. Those 
at the level of the lesion are lost. There may be loss of control 
of the sphincters, bed-sores, degenerative changes in the paralyzed 
muscles, contractures, and vasomotor disturbances. The paralyzed mus- 
cles may be rigid or flaccid, according to the seat and extent of the 
lesion. 

When transverse myelitis is situated in the cervical region there is 
paralysis and anesthesia of the arms, legs, and trunk. All the reflexes 
are exaggerated, and there is general rigidity of the paralyzed muscles. 
There is incontinence of feces and retention of urine, followed by in- 
continence from overflow. The pupils are frequently contracted, and 
there may be optic neuritis. Atrophy, when present, usually affects the 
muscles of the arms, and indicates that the cord to a considerable extent 
is involved.' There is great danger to life, owing to paralysis of the 
muscles of respiration. 

When the seat of disease is the dorsal region, the symptoms arc simi- 
lar to those above described, with the exception that the arms escape, 
and that the ocular symptoms are usually wanting. This is the most 
favorable scat of the disease. 

When the disease is situated in the lumbar region, in addition to 
paraplegia and anesthesia of the legs, there is, from the beginning, in- 
continence of urine and feces. T he knee reflexes are lost ; (he muscles 
atrophy, and usually give the reaction of degeneration. Bed-sores are 
frequent. 

In diffuse myelitis the symptoms are a combination of the above 
groups. If a large part of the cord is involved, there are general paral- 



804 DISEASES OF THE NERVOUS SYSTEM 

ysis and anesthesia, loss of reflexes, marked trophic disturbances, bed- 
sores, etc. 

The course of myelitis is slow, and it usually progresses steadily from 
bad to worse. Death is due to exhaustion or complications — cystitis, bed- 
sores, or hypostatic pneumonia — or to some intercurrent disease. In a 
small proportion of the cases there may be partial recovery, but very 
rarely is recovery complete. The diagnosis is to be made from spinal 
meningitis, tumors, and hemorrhage. 

Treatment. — The treatment of the early stage consists in the use of 
ice to the spine, or counter-irritation by means of dry cups or mustard. 
Later, the iodid of potassium should be given in full doses ; improvement 
may follow its use, even when there is no suspicion of syphilis. Elec- 
tricity is contraindicated except in chronic cases, and then but little 
improvement is likely to result from its use. In these patients the most 
important thing is careful attention to cleanliness and to posture, in 
order to prevent bed-sores, cystitis, and pneumonia. 



COMPRESSION - MYELITIS 

(Pressure-paralysis of the Spinal Cord; Pott's Paraplegia) 

Compression-myelitis is sometimes traumatic, but usually follows 
caries of the spine. It most frequently complicates this disease when the 
cervical or upper dorsal vertebrae are involved, rarely when the lower half 
of the spinal column is affected. This difference is probably due to the 
smaller size of the spinal canal in its upper portion. According to Gib- 
ney, paraplegia is seen in fifty per cent of the cases of caries of the upper 
half of the spine. Essentially the same condition, so far as the cord is 
concerned, may result from tumors of the spinal cord, or from anything 
else causing pachymeningitis. These, however, are exceedingly rare in 
childhood. 

Lesions. — In spinal caries there occurs as a result of .tuberculous 
disease a softening of the bodies of the vertebrae, which fall together from 
the pressure due to the superincumbent weight of the body. This causes 
a backward projection known as the kyphosis, or angular deformity. The 
spinal canal is encroached upon by the remains of the vertebral bodies 
whose ligamentous attachments have been loosened, and also by inflam- 
matory products, the result of periostitis, and localized inflammation of. 
the dura mater, chiefly of the external layer, but which sometimes affects 
the internal layer also. All these conditions lead to the production of a 
mass of inflammatory material, often containing tuberculous deposits, 
which is chiefly in front of the cord, but may surround it. The compres- 



COMPRESSION-MYELITIS 805 

sion takes place slowly in most of the eases, from the gradual progress of 
the lesions mentioned. In a small number of cases there may be a 
sudden pressure from the slipping backward of one of the vertebral 
bodies. 

In recent cases the cord at the seat of compression is a little smaller 
than normal. It is usually involved to the extent of from half an inch 
to two inches. Paraplegia may have existed when the changes found in 
the cord are very slight, and sometimes when no changes are visible to 
the naked eye. In more protracted and more severe cases, the cord is 
much smaller at the point of disease, and under the microscope shows 
the changes of interstitial myelitis (Gowers) with meningitis. In old 
cases there is degeneration of the nerve elements, atrophy, and some- 
times disappearance of the ganglion cells, with more or less destruction 
of the nerve fibers ; sometimes all distinction between the gray and white 
substance is lost. In addition to these marked changes at the point of 
pressure, there may be ascending or descending degeneration, as from 
other focal lesions. There is usually inflammation of the nerve roots, 
which have also suffered compression. It is in many cases surprising 
to see to what degree the cord may be compressed and still preserve its 
functions. 

Symptoms. — In caries of the cervical region the symptoms of com- 
pression-myelitis not infrequently precede the deformity, and, in fact, 
the other objective symptoms of bone disease. The earliest symptoms of 
caries usually arise from irritation of the nerve roots, and consist of 
acute pains often not referred to the spine, but radiating to the different 
regions to which these nerves are distributed. They are felt in the neck, 
in the chest, in the epigastrium, and sometimes in the loins. Accom- 
panying these pains, there is noticed a gradual weakness in the lower 
extremities, and sometimes also in the arms, according to the location 
of the disease. This may steadily increase for several weeks until there 
is complete paralysis. Other symptoms are then commonly present. 
There is usually some degree of anesthesia, and there may be numbness, 
tingling, formication, and pain. The sphincters are not often involved. 
When the disease is in the upper half of the cord, there is rigidity of 
the extremities and great exaggeration of all the reflexes, with marked 
ankle-clonus. In the rare cases in which the lumbar enlargement is in- 
volved, there may be loss of reflexes, paralysis of the sphincters, and bed- 
sores. 

The distribution of the paralysis will depend upon the point of com- 
pression. If this is in the cervical region, all tour extremities will be 
paralyzed; if in the dorsal region, only the legs. According to the extenl 
of the secondary lesions in the cord, there may occur muscular atrophy 
and contractures. With disease in the upper cervical region, death may 



806 DISEASES OF THE NERVOUS SYSTEM 

result from sudden pressure upon the cord, owing to a dislocation of the 
odontoid process; or there may be vomiting, pupillary symptoms, irri- 
tation of the phrenic nerve causing hiccough, or pressure causing paral- 
ysis of the diaphragm. 

Course and Prognosis. — These depend much upon the treatment of 
the case. In many cases of paralysis occurring early in caries, complete 
recovery takes place in the course of a few weeks, sometimes in a few 
days, after the application of a proper mechanical support. In the cases 
which have been long neglected, or those in which the paralysis develops 
while proper mechanical treatment is being carried out, the chances are 
not so good. Gibney gives the following statistics of 133 cases under his 
personal observation: 31 proved fatal; 9 dying from myelitis, 14 from 
other diseases subsequent to recovery from the paralysis, and 6 from tu- 
berculosis before complete recovery; 74 recovered from the paraplegia; 
27 were recorded as improved or still under treatment. Relapses oc- 
curred in about fifteen per cent of the cases. The usual duration of the 
paralysis is from three months to two years. Recovery has often taken 
place in cases that have persisted for four or five years. 

Diagnosis. — This is rarely difficult. Spinal caries should be sus- 
pected in every case when the symptoms point to transverse myelitis 
coming on without definite cause. 

Treatment. — The indications are the removal of pressure and the 
fixation of the spine by a proper mechanical support. From his very 
extensive experience, Gibney has more confidence in the iodid of potas- 
sium than in all else except mechanical treatment. Large doses are 
required, often from sixty to ninety grains being given daily for 
months. The iodid should always be largely diluted. Patients should 
be kept scrupulously clean, and the position changed frequently to pre- 
vent the formation of bed-sores. Electricity is contraindicated. When 
the paralysis develops rapidly or occurs suddenly, relief may sometimes 
be obtained by the operation of laminectomy ; but little is to be expected 
from this in the slow cases. 



ACUTE POLIOMYELITIS 

(Epidemic Poliomyelitis; Acute Infantile Paralysis) 

There are few diseases regarding which our knowledge has increased 
so rapidly during recent years as acute poliomyelitis. The first great 
step in advance was made by Landsteiner and Popper, who, in the sum- 
mer of 1909, succeeded in producing the disease in a monkey by intra- 
peritoneal inoculation with the spinal cord of a patient dying of acute 



ACUTE POLIOMYELITIS 807 

poliomyelitis. They were not successful in carrying the transmission 
further. Shortly after this Flexner and Lewis, using the intracranial 
method of inoculation, had no difficulty in reproducing the disease 
and transmitting it through an indefinite series of monkeys.. No other 
animal seems to be susceptible. These observations, now many times 
repeated, have not only definitely established the infectious character of 
poliomyelitis, but have cleared up many doubtful points in its pathology. 

Acute poliomyelitis is now regarded as a communicable, infectious 
disease which prevails both epidemically and sporadically. Although 
possibly its most characteristic lesions are in the anterior horns of the 
cord, any part of the central nervous system may be affected. The 
changes in the cord substance are preceded by lesions of the meninges. 
Although the name poliomyelitis is still retained, the scope of the term 
has been greatly widened. 

This disease is characterized by an acute onset, with fever and usu- 
ally other marked constitutional and nervous symptoms, from which 
there may be rapid recovery; but generally there follows early and ex- 
tensive loss of power. After this there is usually seen a gradual im- 
provement, and sometimes complete recovery. More often, however, 
there is left some permanent paralysis in certain groups of muscles, 
which undergo rapid and marked atrophy. Formerly, poliomyelitis was 
seen chiefly as a sporadic disease; but since the year 1905 epidemics have 
occurred with increasing frequency in various parts of the world, and 
especially in the United States since 1907. As it is most frequently 
seen in very young children, and as it is altogether the most common 
form of paralysis at this period, the old term "acute infantile paralysis" 
is perhaps the most appropriate clinical designation. 

Etiology. — Fully eighty per cent of the cases are seen in the first 
four years of life, the greatest incidence being in the second year. No 
age is exempt and in some epidemics the proportion of adult cases is 
quite large. Epidemics thus far observed have invariably occurred in the 
warm months; those in the United States, from July to October. Fully 
four-fifths of the sporadic cases also are seen during these same months. 

The prevalence of poliomyelitis in an epidemic form began with 
the outbreaks in Sweden and Norway in 1905 and 1906. These were 
followed in 1907 by the epidemic occurring in New York City and vicin- 
ity in which there were observed nearly 3,000 cases. After that polio- 
myelitis gradually spread over the country, epidemics occurring during 
the next Four years in nearly all parts of Hie United Stales. Large 
outbreaks were also reported in other parts of the world. The mosl 
extensive epidemic known was that of New York in L916 in which over 
4,000 cases were reported in a single month. 

The simultaneous or successive occurrence of several cases in the same 



808 DISEASES OF THE NERVOUS SYSTEM 

family has long suggested that the disease was directly communicable. 
This has now been established by experimental evidence and is corrob- 
orated by clinical observations. The disease may be communicated: (1) 
by the typical acute paralytic cases; (2) by mild, ambulant or abortive 
cases; (3) by healthy carriers, i. e., persons who have been in close contact 
with one suffering from an acute attack; (4) by chronic carriers or those 
who have recovered from acute attacks. How long persons of the last two 
groups may convey the disease is not known. The virus has, however, 
been demonstrated on the mucous membranes of the mouth and nose 
after several months have passed. The disease, in most circumstances, 
is feebly contagious, and only a small proportion of those exposed con- 
tract it. As in the case of cerebrospinal meningitis, it is much more 
contagious when prevailing epidemically. The transmission by healthy 
carriers, though very exceptional, is undoubtedly the explanation of the 
occurrence of some of the widely separated cases seen in a community; 
others of obscure origin may be traced to abortive cases. That the virus 
of poliomyelitis is carried by insects has not been established. At pres- 
ent we know of no other way of acquiring the disease than by contact 
with affected persons or with those who serve as carriers. 

The period of incubation of the experimental disease in monkeys 
varies from four to thirty-three days, the average being nine or ten 
days. In man, also, it is variable, but in most instances the second case 
in a family has followed the first one within ten days. 

The specific organism of this disease belongs to the class of filtrable 
viruses. It passes through the pores of the finest porcelain filter. It 
has been isolated and cultivated outside the body by Flexner and No- 
guehi, and with a high-power microscope it can be seen as very minute 
globular bodies. It is present in largest quantity in the diseased nerve 
structures, particularly the spinal cord. In the earliest stages of the 
attack it is also found in the cerebrospinal fluid, but disappears at 
about the time paralysis occurs. It exists to some extent in other tissues 
of the body, particularly the lymph nodes. The disease can be trans- 
mitted to animals regularly and with certainty only by inoculation with 
an affected spinal cord, in which the virus persists for months after the 
acute attack. Experiments and clinical evidence indicate that the usual 
path of entrance is the nasal mucous membrane. Osgood and Lucas 
have shown that the virus persisted in the nasal mucous membrane of 
monkeys, in one instance for five months, in another for one and a half 
months, after the acute attack ; which suggests that this may not only 
be an avenue of entrance, but possibly a mode of elimination of the in- 
fection, and indicates that the duration of the infective period may at 
times be a very long one. 

Lesions. — As a result of the investigations, particularly of Flexner 



ACUTE POLIOMYELITIS 809 

and Lewis upon animals, and those of Harbitz and Scheel, Strauss, and 
others upon the disease in man, the pathology of acute poliomyelitis is 
now well known. This knowledge has greatly aided our clinical under- 
standing of the disease. 

The lesions found in this disease show in the cases severe enough to 
be fatal the effects of a widespread generalized infection. Not only are 
the nervous tissues involved, but also the parenchymatous organs and 
lymphoid structures. In the nervous system the virus first attacks the 
meninges, especially of the cord and medulla, setting up a cellular in- 
flammation of the pia, which becomes infiltrated with small, round cells. 
These changes are most marked about the blood-vessels. Besides this 
the walls of the vessels themselves are infiltrated and their lumen nar- 
rowed. The lesion also affects the vessels entering the nerve structures. 
As a result of the vascular lesions anemia, edema, and hemorrhages are 
present, sometimes small and circumscribed, sometimes quite diffuse and 
extensive. Thrombosis seldom occurs. But more important still are 
the secondary degenerative changes in the nerve cells, the site and extent 
of which are determined by the vessels involved and the intensity of the 
changes in them. The lesions in the pons, medulla, and cerebrum, like 
those in the cord, are secondary to the vascular lesions. 

The transient paralysis in cases that recover may be due to edema or 
to temporary vascular obstruction from pressure outside the vessel- 
causing a local anemia. Permanent paralysis depends upon severe de- 
generation and actual destruction of ganglion cells; its extent, there- 
fore, will vary with the number of the ganglion cells affected. Any part 
of the central nervous system may be affected, and the lesions are gen- 
erally more extensive than the symptoms would lead one to expect. The 
gross appearances give but little idea of their severity. The process 
often involves nearly the whole length of the cord, being, however, gen- 
erally most marked in the cervical and lumbar enlargements. The 
changes are chiefly in the gray matter of the anterior horns, and consist 
in acute degeneration of ganglion cells, usually marked and extensive. 
These cells in certain parts may disappear altogether, being replaced by 
Leucocytes. The entire cord, however, may be involved. There is seen. 
but to a much less degree, infiltration with small round cells of the pos- 
terior horns, the columns of Clarke, and the white matter of the cord, 
everywhere closely related to the blood-vessels. There are regularly 
found changes in the spinal ganglia of ;i similar character to those 
described in the cord. 

Lesions like those of the cord, though generally less marked, arc 
seen in the pons, the medulla, the cerebellum, and even in the cerebral 
hemispheres. They are, as in the cord, especially related to the pia and 
the blood-vessels. There is seen acute dot met ion of ganglion cells 



810 DISEASES OF THE NERVOUS SYSTEM 

and areas of cell infiltration with lymphocytes. The changes are espe- 
cially marked about the nuclei of the cranial nerves, and in the gray 
matter about the fourth ventricle. In some cases the basal ganglia 
are also involved. Areas of infiltration, sometimes quite diffuse, may 
be seen in the cortex, with also some slight degeneration of ganglion 
cells. 

Thus, in the severe and fatal cases there is present a diffuse inflam- 
mation of the entire cord and its membranes, also of the medulla, pons, 
and basal ganglia, with less marked changes in the cerebrum, always 
accompanied by changes in the pia. In the milder cases it is probable 
thai; the inflammatory changes are limited to the cord, though in some 
patients dying later from other causes Harbitz and Scheel discovered 
changes in the upper centers, though no symptoms pointing to them 
had been present. From this account of the lesions it would appear 
that we can no longer distinguish between the lesions of acute polio- 
myelitis, acute bulbar paralysis and acute porencephalitis inferior. They 
represent varying phases of one and the same disease. In recent acute 
cases no changes are usually found in the nerves except degeneration of 
bundles, corresponding to the degenerated areas in the cord, and prob- 
ably secondary to them. Lesions in other organs are often present, the 
most frequent being bronchopneumonia and acute parenchymatous de- 
generation of the liver and kidneys, similar to what is seen in other 
severe general infections. The thymus, the solitary follicles of the in- 
testine, and the mesenteric glands may be much swollen. 

In autopsies made upon cases of long standing the affected part of 
the cord, which is often only one lateral half, is smaller than normal. 
The general changes are those of a sclerotic character. The ganglion 
cells of the affected anterior horn have either disappeared altogether, or 
they are few in number and so shrunken as to be hardly recognizable. 
The white matter also is smaller than in the sound part of the cord. 
The anterior nerve roots are degenerated quite to the muscles. The 
affected muscles are atrophied, and in extreme cases there may be a 
complete disappearance of muscle fibers, their place being taken by adi- 
pose and fibrous tissue. In places where the lesion is less severe the 
fibers are small. The affected limb is shorter and the bones smaller 
than upon the sound side. 

Symptoms. — Cases of acute poliomyelitis present a wide variety of 
clinical symptoms depending upon the virulence of the infection, the 
age of the person attacked, but principally upon the part of the nervous 
system chiefly involved in the pathological process. They may be broadly 
divided into four general groups: (1) the cerebral cases; (2) the spinal; 
(3) the bulbospinal; (4) the non-paralytic or so-called abortive cases. 

The Cerebral Type. — -It is only very recently that acute poliencepha- 



ACUTE POLIOMYELITIS 811 

litis, fully described by Striimpell in 1885, has been regarded as a mani- 
festation of this disease. Although some experimental evidence is still 
wanting, the identity of the histological changes and its association with 
acute poliomyelitis in epidemics leave little doubt that acute polienceph- 
alitis is often only the cerebral form of acute poliomyelitis. Such cases are 
not to be confounded with the common forms of acute poliomyelitis with 
cerebral symptoms. 

. The onset is generally abrupt, with convulsions which are often re- 
peated over a period of a day or Wo. There is usually vomiting and 
fever, which may be high. The paralysis which follows after one to 
three days of general symptoms is usually of the hemiplegic type, the 
face, arm and leg being involved. The reflexes are increased and the 
paralysis is of the spastic type. The face improves and usually recovers 
completely; the leg, next; while the arm is generally most affected and 
the paralysis is likely to be permanent and be followed by contractures. 
In its late results it resembles other forms of acute cerebral paralysis in 
early life. 

The Spinal Type. — This group includes the most characteristic form 
of the disease and is numerically the largest. In the cases of moderate 
severity, the onset is abrupt and the symptoms may differ little from 
those seen in other acute infections. There is usually vomiting, which 
is not repeated, more frequently constipation than diarrhea, and fever 
which is generally not over 103° F. Drowsiness, irritability, headache 
and prostration are seen in most cases. After the first day more definite 
symptoms, indicating involvement of the nervous system, are present- 
general hyperesthesia, shooting pains in the legs, stiffness of the neck or 
extremities, pain on motion, etc. The blood shows a moderate polymor- 
phonuclear leucocytosis and the cerebrospinal fluid is generally clear, 
but may be slightly opalescent. It shows a greatly increased number of 
cells, which at first may be chiefly polymorphonuclear, but very soon are 
nearly all lymphocytes. There is an increase of globulin. After the 
febrile symptoms have lasted for from twenty-four hours to three days, 
the paralysis is seen. Exceptionally, the early stage is very short, and the 
paralysis is noticed almost at the onset. In the lighter cases, the fever 
may not be over 100° or 101° F., and may last only a day, with all the 
general and local symptoms correspondingly mild, though the resulting 
paralysis may be extensive. 

In the paralytic stage the loss of power sometimes comes on quickly 
in a few hours; but more often, rather gradually, and extends for from 
two to three days before it is fully developed. The other nervous symp- 
toms usually continue. The posture is in most cases dorsal, with limbs 
semi-flexed, but in some cases with marked meningeal irritation there 
may be a general flexion of the body with opisthotonus, exactly as in 



812 DISEASES OF THE NERVOUS SYSTEM 

cerebrospinal meningitis. The same rigidity of the neck and extremities 
may also be seen. The knee jerks are not uniform, at first may be in- 
creased, but are soon lost on the paralyzed side and sometimes also on 
the sound side. Pain is present on motion, on pressure over nerve trunks 
and sometimes complained of when the patient is quiet. Eetention of 
urine may be so complete as to require the use of the catheter, but in 
most cases the child is able to void, however, with considerable diffi- 
culty. The bowels in most of the cases a^e constipated. The mind is usu- 
ally clear, though the child is very sensitive to handling, and there may 
be general hyperesthesia. The duration of the fever is on the average 
three or four days; it is rare for it to continue longer than a week. 
The temperature range is generally between 101° and 103°, and the 
fall to normal is gradual. Usually the height of the temperature is in 
proportion to the severity of the infection, but it does not measure the 
danger of the attack, which depends rather upon what part of the 
nervous system is involved most seriously. 

The description above given is that of the type most frequently met 
with, but many other forms of the disease are seen which add much to 
the difficulty of diagnosis. Certain cases present marked cerebral symp- 
toms, chiefly stupor, with very few spinal symptoms. After the usual 
onset, the drowsiness soon develops into deep stupor, which may last 
for a week or more. These symptoms, with the continuance of the fever, 
the stiffness of the neck and irregularity of the knee jerks, form a pic- 
ture which is almost indistinguishable from tuberculous meningitis. 
These cases belong to quite a different group from those described above 
as the cerebral type. The paralysis, when it occurs, indicates an in- 
volvement of the cord at a high level and affects, besides other parts, 
one or both arms. Though the symptoms in such cases are most dis- 
turbing, the cerebral condition often clears up rapidly and completely. 

Other types which may be seen in epidemics are : (1) those in which 
the symptoms of meningeal irritation are especially marked, extreme 
muscular and nervous irritability, hyperesthesia, rigidity, etc., a group of 
symptoms strongly suggesting cerebrospinal meningitis; (2) cases in 
which, with many of the above symptoms, pain is especially prominent; 
(3) cases in which gastro-intestinal symptoms are particularly marked; 
both vomiting and diarrhea may last for several days and their prom- 
inence may obscure the nervous symptoms. 

The Bulbospinal Type. — The onset and general symptoms differ in 
no way from the severe cases of the spinal type. It is only after paralysis 
develops that the characteristic symptoms are seen. This group forms, 
according to Wickman, about 6 per cent of the epidemic cases. The 
lesions of the bulb are generally more extensive than one would expect 
from the symptoms. The symptoms of bulbar paralysis are nearly 



ACUTE POLIOMYELITIS 813 

always limited to one side, whether they occur alone or with paralysis 
of the arms and legs. Almost any of the cranial nerves may be in- 
volved, altogether the most frequent being the facial. The whole nerve 
is not always affected. The facial paralysis is usually transient, but 
may be permanent. Ocular paralyses are next in frequency, the external 
rectus being oftenest affected. Disturbances of speech are not infre- 
quent, but rarely persist. They are often associated with disturbances 
of deglutition, which, while not common, may be so severe as to necessi- 
tate feeding through a tube. With these bulbar symptoms are often 
associated others, indicating involvement of the upper part of the cord, 
such as paralysis of the diaphragm, the intercostals, the neck, or the 
upper extremities. These cases form the most severe and fatal type of 
acute poliomyelitis met with, and it is the type that furnishes most of the 
deaths. The fatal result is nearly always from respiratory paralysis or 
bronchopneumonia. 

Acute bulbar paralysis with lesions limited to this part, though for- 
merly described as a separate and distinct disease, is probably only a 
form of acute poliomyelitis. 

Another rare clinical type is an acute ascending paralysis with symp- 
toms described as Landry's disease. After the usual onset, paralysis 
affects first the legs, then the arms, the neck and finally the diaphragm 
and intercostals, with death from respiratory paralysis. This extension 
of the paralysis usually occupies three or four days, though it is some- 
times very rapid, and death may take place on the second or third day 
from the beginning of the attack. 

Extent and Distribution of the Paralysis. — Wickman gives the fol- 
lowing grouping of 868 epidemic cases in 1905 : 

One or both legs 353 ; one or both arms 75 

Combinations of arms and legs. . . 152; legs and trunk 85 

Arms and trunk 10; trunk alone 9 

Ascending paralysis 32; descending paralysis. ... 13 

Spinal and cranial nerves 34; cranial nerves alone. ... 22 

Whole body 23; not given 60 

A comparison between this and 560 sporadic cases we have collected 
from various authors is interesting: 

One leg 229; both legs 17(> 

Combinations of arms and legs.. . 42; one arm only 14 

All extremities and trunk 79; all others 10 

In both series the large proportion of cases in which ilie legs are 
involved is striking; also the in frequency with which the anus alone arc 
affected, and finally that in the epidemic cases there is a much larger 



814 DISEASES OF THE NERVOUS SYSTEM 

number with widespread paralysis and with cranial nerve involvement. 
The latter, when occurring sporadically, are generally classed under 
some other heading than acute poliomyelitis. 

The paralysis, when limited to the leg, most frequently affects the 
anterior tibial group; next, the peroneal, and third, the quadriceps ex- 
tensor femoris. The paralysis of the upper extremities most often in- 
volves the shoulder group, the deltoid being the muscle which usually 
suffers most severely. Paralysis of the sphincters is .very rare, though 
bladder disturbances are quite common. 

. The most serious paralysis is that of the diaphragm and the inter- 
costals; either may be involved alone and the patient recover, but when 
both are affected death follows. Diaphragmatic paralysis occurs when 
the lesion affects the third to the fifth cervical segments of the cord. 
It seldom occurs early and may develop quite late in the disease. Though 
this is always a serious symptom, it may last several days and yet re- 
covery take place. When the diaphragm is paralyzed, all the accessory 
muscles of respiration are called into action; the respiration is wholly 
thoracic and the abdominal wall, instead of protruding, is retracted on 
inspiration. 

Paralysis of the intercostals is rare, except in very severe cases, and 
is usually, but not invariably, fatal. It is seen in association with wide- 
spread paralysis of arms and legs, and in the rapidly spreading cases of 
ascending paralysis, and in the most severe infections. The respiration 
in intercostal paralysis is purely diaphragmatic, which is not always 
easy to recognize, as it is an exaggeration of the normal infantile type. 
When both intercostals and diaphragm are involved, we see one of the 
most distressing conditions seen in the disease, i.e., death by respiratory 
paralysis. A remarkably vivid picture of this is given in the monograph 
of Peabody, Draper and Dochez. The mind is usually clear, alert and 
full of apprehension. Every breath drawn is with severe effort. Sweat- 
ing is profuse. Cyanosis is usually absent. The struggle may last for 
several hours before death takes place. Although life may sometimes be 
prolonged for a considerable time by artificial respiration, there is prac- 
tically no hope of recovery. 

Paralysis of the abdominal muscles is not common, is usually of one 
side, but niay affect both. It is evident by a great bulging or "balloon- 
ing" of part of the abdominal wall, in coughing, sneezing, or any forced 
expiration. It may remain as a permanent paralysis. 

Course of the Disease. — In those who survive the acute stage, there 
is a period of a few weeks' duration in which little change is seen. This 
is followed by spontaneous improvement, which usually begins in the 
muscles last affected, and reaches its limit in from three to six months. 
The paralysis remaining after this time is likely to be permanent. By 



ACUTE POLIOMYELITIS 



815 



the end of six or eight weeks atrophy is present in the paralyzed muscles. 
The affected limb is distinctly smaller than its fellow, this being quite 
apparent even in infants. Except in the early stage, sensory disturb- 
ances are absent; the knee-jerk is lost in paraplegic cases, and in those 
in which the extensors of the thigh are paralyzed. There is arrested 
growth in the whole limb (Fig. 125). It becomes much smaller and 
shorter than its fellow. From paralysis of the shoulder and thoracic 
muscles various chest deformities may result (Fig. 126). The great 
relaxation of the liga- 
ments at the joints may 
allow subluxation, espe- 
cially at the knee and at 
the shoulder. The circu- 
lation in the affected 
limb is poor; it is often 
blue and cold. 

Very early in the dis- 
ease the atrophied mus- 
cles begin to lose their 
power to respond to fa- 
radism. In the muscu- 
lar groups which are to 
be permanently par- 
alyzed, the faradic re- 
sponse may be lost in a 
week. The muscles in 
which recovery is to take 
place often preserve a 
certain degree of con- 
tractility. The response 
to the galvanic current 
may be increased for a 

few months, and then slowly fail as the muscular fibers themselves degen- 
erate, and finally it may disappear altogether. The reaction of degenera- 
tion is present in the atrophied muscles, but in them alone. 

Non-Paralytic Cases. — The terms "abortive" or "ambulant" are 
sometimes used to designate cases of acute poliomyelitis in which all the 
usual early symptoms of the disease are present, yet which recover with- 
out definite paralysis having developed. In some of these cases there is, 
however, a general muscular weakness. These represent instances of 
infection in which the nervous system either escapes altogether, or is so 
slightly involved as to give no definite symptoms. That such cases exist 
there can be no doubt. It is believed by many writers that in number 




Fig. 125. — An Old Case of Infantile Spinal Paraly- 
sis of the Entire Left Lower Extremity. 
Showing extreme atrophy of the thigh and leg, and 
a very characteristic deformity of the foot. 



816 



DISEASES OF THE NERVOUS SYSTEM 



they equal or possibly exceed the paralytic cases. The evidence that they 
are genuine cases of acute poliomyelitis is not only their frequent clinical 
association in epidemics with frank cases, but has now, according to Flex- 
ner, been definitely established by laboratory findings, viz. : (1) there are 
certain characteristic changes in the cerebrospinal fluid — increased num- 
ber of cells chiefly lymphocytes and the presence of globulin; (2) there 
has been demonstrated in the blood neutralizing immunity principles, 
such as are found in persons suffering from typical attacks, but not pres- 
ent in normal blood; (3) the virus has been detected on the nasal and 

buccal mucous membranes in such quan- 
tities as to make possible the communi- 
cation of the disease to monkeys. 

The recognition of non-paralytic 
cases of acute poliomyelitis has clarified 
many points in the spread of the disease. 
Poliomyelitis may be suspected by the 
fact of the attack occurring in close asso- 
ciation with other typical paralytic cases ; 
but there is nothing diagnostic in the 
clinical symptoms; the absolute diag- 
nosis rests upon the laboratory evidence 
above cited. 

Diagnosis. — The recognition of acute 
poliomyelitis before the occurrence of 
paralysis is impossible except by lumbar 
puncture. If this is performed early, the 
cerebrospinal fluid is found to be clear 
or slightly opalescent. The number of 
cells may be as many as 1,000 per c. mm. 
At first these may be nearly all polymorphonuclear; but soon they are 
replaced by lymphocytes, which generally form over 90 per cent of the 
cells seen. The test for globulin gives a positive reaction. By the time 
paralysis appears the cells have diminished greatly in number and soon 
the fluid may show no change by which it can be distinguished from 
the normal except an increased number of cells and an increased globulin 
reaction. The usual fluid found in acute poliomyelitis resembles that of 
tuberculous meningitis, which some cases closely simulate in their clini- 
cal symptoms. The v. Pirquet skin test is often a great aid in diagnosis ; 
but in many instances one must wait two or three days for the course of 
the disease to declare itself, or until tubercle bacilli can be found in the 
cerebrospinal fluid. Cases with muscular pains, general hyperesthesia, 
rigidity and high fever may easily be confounded with cerebrospinal 
meningitis. It can be excluded only by lumbar puncture. 




Fig. 126. — An Old Case of Infan- 
tile Spinal Paralysis of the 
Left Arm and Shoulder 
Muscles, with Resulting 
Lateral Curvature. 



ACUTE POLIOMYELITIS 817 

The later manifestations of the spinal type of poliomyelitis are a 
flaccid type of paralysis with marked atrophy and characteristic electri- 
cal reactions, but without sensory symptoms. It may be confounded with 
multiple neuritis, or the pseudo-paralysis of rickets. Multiple neuritis 
is rare in children except after diphtheria, and is more gradual in its 
onset. The type of paralysis and the electrical reactions may be the 
same as in poliomyelitis. Certain birth palsies, resulting from injuries 
received during delivery, may resemble poliomyelitis when the deltoid 
or shoulder group of muscles is involved. Without a clear history a dif- 
ferential diagnosis may be impossible. The muscular weakness of rick- 
ets is general; there is no reaction of degeneration and no history of 
acute onset. Scurvy is distinguished by the very acute hyperesthesia, 
by the swellings, and by hemorrhages from the gums or other mucous 
membranes together with a history of improper feeding. The child 
refuses to move his legs only because of pain. The cerebral form of 
poliomyelitis gives a spastic paralysis, usually hemiplegic in type, which 
may be indistinguishable from other forms of acquired cerebral paralysis. 

Prognosis. — The dangers from poliomyelitis are twofold: that to life 
during the acute stage, and that to muscles in the form of permanent 
paralysis and disability. The mortality is much higher in epidemic 
than in sporadic cases. The death rate in the various large epidemics 
has ranged between 10 and 20 per cent. The danger to life is least in 
infants and very young children. In cases terminating fatally death 
usually occurs between the fourth and seventh days of the disease. The 
cause of death is generally respiratory paralysis or bronchopneu- 
monia. 

It is impossible to say in any case of advancing paralysis when it 
will be arrested. It rarely spreads after the seventh day. An important 
question in prognosis is whether paralysis will be permanent or not. 
Wickman reports recovery from paralysis in 44 per cent of 530 epidemic 
cases. This is a larger proportion than most writers give, and much 
larger than we have ourselves observed. Complete recovery from paral- 
ysis in 20 to 25 per cent of the cases is much nearer the average 
result. 

Significant symptoms in any given case are the amount of wasting 
and electrical reactions. Muscles which soon lose completely their 
faradic contractility are almost certain to waste rapidly ami severely. 
The best indication of coming improvement is the return of faradi< 
contractility. If this is completely lost for six months, recovery is verj 
doubtful; if faradic contractility is not lost, great and early improve- 
ment in the paralyzed muscles may be confidently predicted. After six 
months but little spontaneous improvement is to he looked for. and after 
two years none at all. 



818 DISEASES OF THE NERVOUS SYSTEM 

Tteatment. — The communicable character of the disease being now 
established, it follows that all cases of acute poliomyelitis should be iso- 
lated; when the disease is epidemic this is imperative. It is not now 
known how long a given case may be infectious. A month's quarantine 
may be considered a minimum; but during epidemics a longer time 
should pass before an affected person should be allowed to mingle with 
other children. All discharges, especially those from the mouth and 
nose, should be disinfected and destroyed. Persons in contact with ac- 
tive cases should use some cleansing nasal spray or mouth wash as the 
only means now known for preventing infection. The same cleansing 
and disinfection of apartments should be practiced as after other infec- 
tious diseases. 

Since we have as yet no specific remedy for poliomyelitis, the treat- 
ment during the acute stage is symptomatic and to be conducted along 
the same general lines as other acute infections. Hexamethylenamin 
(urotropin) has been extensively used in this disease, in doses of five to 
ten grains four times a day to a child of three or four years, but there 
is no convincing proof that any drugs are effective in aborting the dis- 
ease or preventing or arresting paralysis. Absolute rest is essential, even 
in the mildest cases, and should be continued for an average period of 
two weeks; longer when irritative symptoms are protracted. Pains in 
the affected limbs during the acute stage may be lessened by the applica- 
tion of splints to insure immobilization and also at times by wrapping 
limbs in cotton. There should be as little handling as possible. It is 
important to support the limbs, so as to lessen the chances of deformity. 
There should be placed at the feet pads or sand-bags, to prevent foot- 
drop, which otherwise is almost certain to occur in cases of anterior tibial 
paralysis. Severe pain may require the administration of morphin or 
codein. Paralysis of respiration in the acute stage is practically beyond 
help. Feeding through the tube is sometimes necessary in bulbar cases 
for a considerable time, owing to paralysis of the muscles of deglu- 
tition. 

When all acute symptoms have subsided, which is generally in three 
or four weeks, measures should be begun for the development of the 
paralyzed muscles. The beneficial effects of electricity have been greatly 
overestimated. In many cases, however, it is useful, but should never 
be alone relied upon. Faradism may be used three times a week for 
such muscles as respond to it; for other muscles galvanism should be 
employed. The pain and terror which the use of electricity excites in 
most small children makes its continuance a practical impossibility. It 
is far better under such circumstances to rely on other measures. 

Massage and passive movements may be begun as soon as hyperes- 
thesia has gone, and may be used at first daily and soon twice a day to 



TUMOES OF THE SPINAL CORD . 819 

all affected parts. They should be continued for years. But still more 
important are active voluntary movements carried out by the patient 
himself, which should be developed with great care and systematically 
carried out for an indefinite period. It is really surprising what such 
measures when intelligently used can accomplish. 

Mechanical Treatment. — Mechanical appliances are useful to prevent 
deformity, also to furnish support to the limb in order to enable the 
child to walk. By such means many get about with tolerable comfort 
for whom locomotion without apparatus is impossible except with 
crutches. To overcome existing deformities in neglected cases, braces are 
employed in conjunction with myotomy or tenotomy of the various short- 
ened tendons, excision of portions of elongated tendons, and the produc- 
tion of artificial anchylosis in cases of "flail joints." By these means the 
orthopedic surgeon is able to give a great deal of relief to these unfor- 
tunate and sometimes helpless patients. 



TUMORS OF THE SPINAL CORD 

Tumors of the cord are exceedingly rare in children and almost 
unknown in infancy. They spring from the bone, from the meninges, 
or from the cord itself. The most common meningeal tumors are sar- 
comata, fibromata and lipomata, the last named being found in asso- 
ciation with spina bifida. In the cord gliomata, sarcomata, solitary 
tubercles and gummata may be encountered. 

The first and most important symptom is pain. This may be in 
the extremities or in a girdle form around the body. Associated with 
the pain may be a zone of hyperesthesia. Eventually there may be 
anesthesia. Motor symptoms are manifested sooner or later. There 
may be contractures or tonic spasm and finally spastic paralysis with 
exaggerated reflexes and ankle clonus. The arms are seldom involved. 
Especially characteristic is the Brown Sequard paralysis — a unilateral 
paralysis with a zone of hyperesthesia upon the paralyzed side and with 
anesthesia upon the opposite side. Paralysis of the bladder and rec- 
tum is present, but is not always an early symptom. 

The diagnosis of tumor is to be made from these general symptoms, 
in the absence of injury or of caries of the spine, which is the most com- 
mon cause of transverse lesions of the cord in childhood^ The localiza- 
tion of the growth is to be made according to the rules of general neu- 
rology. This is difficult in childhood, because the tumors are apt to be 
diffuse (gliomata, sarcomata, tuber culomata) and because of the fre- 
quent inability to obtain the necessary cooperation from the child. The 
general symptoms are also very uncertain. We have seen a fibroma of 



820 DISEASES OF THE NERVOUS SYSTEM 

the meninges in a five-year-old child successfully removed by operation, 
which caused no pain at any time. 

The prognosis is bad. Few cord tumors in childhood are of such a 
character or in such a situation that they can be removed. Unless they 
are malignant, or can be removed, death results from intercurrent dis- 
ease, from bed-sores or from ascending inflammation of the urinary 
tract. The treatment is surgical. If operative removal is impossible, 
nothing can be done except to make the patient comfortable. 



HEREDITARY ATAXIA— FRIEDREICH'S ATAXIA 

While cases of Friedreich's ataxia are encountered with no history 
of a like disease in relatives, the disease is especially likely to attack 
several members of a family in one or more generations. As many as 
eight sufferers from the disease in one generation have been reported, 
and it has been traced through three generations. Friedreich's ataxia 
is for this reason to be classed among the hereditary degenerative diseases 
of the nervous system. Except for this hereditary influence, there is 
no etiological factor known. 

Friedreich's ataxia is an infrequent disease, consisting of two fairly 
distinct types. The type of interest to pediatrists occurs early in child- 
hood, usually between the fourth and seventh year. The other type, 
often known as the Marie type, is seldom found before the twentieth 
year and need not, therefore, concern us here. 

The pathological changes are chiefly in the cord. These consist in a 
diminution in the circumference of the cord throughout its entire extent 
and in a degeneration of various tracts, chiefly the posterior columns. 
The column of Goll is affected throughout, the column of Burdach to a 
greater or less degree, and the crossed pyramidal tract to a slight extent. 
In addition, the cells of Clarke's column are degenerated and there is 
a consequent degeneration of the direct cerebellar tract and the bundle 
of Gowers. There is no degeneration in the cells of the anterior horns. 

Symptoms. — Ataxia is the most striking and usually the earliest 
symptom. It is first noticeable and is always most marked in the legs. 
There is difficulty in walking and even in standing, but the ataxia of 
the legs is noticeable in any position, even when lying down. The chil- 
dren stand with their legs wide apart. In some instances there may 
be a distinct Eomberg symptom, it being impossible for them to stand at 
all with the eyes closed. The gait is ataxic, much like that of locomotor 
ataxia at first, but later it may be so disturbed that the patient reels 
from side to side as if intoxicated. Eventually locomotion is impossible 
(specially when the muscular weakness, which is regularly present, be- 



PROGRESSIVE MUSCULAR WASTING 821 

comes extreme with atrophy. Early in the disease muscular weakness is 
slight. There may be wobbling of the head and there is usually a 
coarse tremor of the arms and hands. Sensation is well retained and 
control over the bladder and rectum is normal. Exceptionally there 
are sharp, lancinating pains in the legs. The knee jerks are commonly 
absent. Slow, scanning, sometimes explosive speech is very frequent and 
late in the disease speech may be nearly impossible. There is often a 
marked nystagmus. A striking symptom is the common deformity of 
the foot. This may be one of the first symptoms to be noticed. The 
foot appears shortened, it is markedly arched and is held in a position 
of slight equino-varus. The great toe is hyper-extended and sometimes 
the terminal phalanx is flexed. Kypho-scoliosis develops with the advent 
of muscular weakness. The intelligence is well retained for a time but 
suffers deterioration in the course of the disease. In the form described 
by Marie, there are often exaggerated reflexes, optic nerve atrophy and 
paralysis of the extra-ocular muscles; but these symptoms are seen in 
children with the greatest infrequency. 

The course of the disease is progressively downward, the ataxia 
becoming more marked and that and the muscular weakness make walk- 
ing impossible. The patient eventually becomes bed-ridden, in a condi- 
tion of dementia. But the progress of the disease is very slow. It may 
last twenty or thirty years or more. Death is usually due to some 
intercurrent disease and is rarely the result of asthenia. Friedreich's 
ataxia is incurable. It can only be treated symptomatically. 



DISEASES ASSOCIATED WITH PROGRESSIVE MUSCULAR WASTING 

A number of diseases in infancy and childhood are accompanied 
by muscular wasting. This may be secondary lo disturbances of nutri- 
tion, to sonic chronic infection or it may result from disuse. Wasting 
is also present with organic diseases of the nervous system, particularly 
as the result of some acute lesion such as poliomyelitis, and also with 
chronic crippling diseases such as spastic paraplegia, chronic meningi- 
tis, etc. But there is a group of diseases in infancy and childhood that 
is characterized chiefly by progressive muscular wasting with greal 
weakness. They develop insidiously and with but few exceptions progress 
uninterruptedly to a fatal termination. They are of greal chronicity 
and are practically incurable. Many show a marked hereditary ten- 
dency. Of these diseases, there are a number of more or less clear cut 
types that may be recognized clinically and pathologically. There are. 
however, very many cases that pathologically, as well as clinically, have 
the characteristics of two or even more types. For this reason, it has 



822 DISEASES OF THE NERVOUS SYSTEM 

been hard to classify these diseases. There has been much difference 
of opinion in regard to them and there are obvious objections to all 
methods of classification. The lesions in some of these cases are 
chiefly in the cord; in others, in the nerves, and, in the largest group, 
in the muscles. We shall therefore group them as the spinal, the neural 
and the muscular forms. 

Spinal Muscular Atrophy. — The spinal forms are unusual in child- 
hood. Chronic bulbar paralysis and the Aran-Duchenne type of spinal 
atrophy are so rare at this age as to be of little importance to pediatrists. 
The other type of central atrophy that has been described, though infre- 
quently, is 

The Werdnig -Hoffmann Type. — This disease is markedly hereditary; 
several children in a family may be affected and the disease has been 
traced through two or three generations. It is not a common disease — 
only twenty or thirty cases in all have been reported. The onset is 
early, usually toward the end of the first year. A weakness in the thighs 
and back develops in a child that up to that time has been entirely 
normal. This weakness extends so as to involve the shoulders, the 
neck, and, eventually, the arms and thighs. The legs and lower arms 
are only involved late in the disease, and the hands and feet rarely 
at all. There is marked atrophy of the muscles, particularly those of 
the pelvis and shoulders. The muscles show at times fibrillary con- 
tractions and there is always loss of deep and generally of superficial 
reflexes. There is a great diminution in response to both faradic and 
galvanic currents. The muscles of the face usually escape entirely. 
Bulbar symptoms are very unusual. Speech is normal and the mentality 
remains unaffected to the end. There is no interference with sensation. 
The progress of the disease is quite rapid. Death usually results in 
two or three years, from respiratory involvement or from pneumonia. 
The localization of the chief muscular paresis and atrophy in the pelvic 
and shoulder girdles, the progressive character of the disease and the 
retention of a clear mentality, distinguish it from the other diseases 
with which it is likely to be confounded which are chiefly: amyatonia 
congenita, poliomyelitis, progressive neural and muscular atrophy and 
amaurotic idiocy. 

The pathological changes are clearly marked. There is an atrophy 
of the spinal cord, with degeneration of the cells in the anterior horns 
throughout its whole extent from the medulla to the cauda equina. 
Secondary to this is a degeneration of the anterior roots of the cord 
and of the motor nerves, with great atrophy of the muscles. There 
are no changes in the pyramidal tracts. 

The progress of the disease is rapid. It is unbroken by periods of 
remission and the outlook is hopeless. No treatment has any effect. 



PROGRESSIVE MUSCULAR WASTING 823 

Neural Muscular Atrophy. — The existence of a form of muscular 
atrophy dependent upon primary changes in the peripheral nerves is 
denied by many authors. We have retained such a classification for 
the reasons that in the peroneal type of muscular atrophy there are 
frequently severe lesions in the nerves, that the type is generally clearly 
marked, and that the disease runs a much more benign course than 
any of the other forms of muscular atrophy. 

Peroneal Type. (Charcot, Marie, Tooth.) — This form of muscular 
atrophy exhibits as marked familial tendencies as any other known 
disease. Examples of it have been met with in five generations and 
it is seldom confined to one member of a generation. Herringham has 
recorded a family in which 26 members had been afflicted with the 
disease. The onset is generally after the sixth year. It begins slowly 
and symmetrically in the distal parts of the extremities, usually the 
legs. The extensor longus hallucis and the extensor longus digitorum 
and the tibialis anticus are usually the first muscles to waste ; afterward 
the peroneal group. The localization of the muscular weakness causes 
inability to flex the foot, which hangs down, causing an impediment to 
walking. To overcome the impediment the knees must be markedly 
flexed, which causes the "stepping" gait. Double club foot in the 
position of equino-varus, often results from unopposed muscular action 
and from attempts to walk. On this account many of the cases first 
come to the attention of orthopedic surgeons. It is uncommon for 
the disease to begin in the hands, but instances of such a mode of 
onset have been reported. The atrophy then affects the small muscles of 
the hands. As the disease progresses the legs and forearms gradually 
become involved but the thighs and upper arms remain free. There is 
no hypertrophy of muscles or pseudo-hypertrophy. There may or may 
not be fibrillary twitching of the muscles. Sensation may be normal 
or there may be complaint of paresthesia, or of feelings of heat and 
cold. Shooting pains may be felt but the pain is never very severe 
and is frequently entirely absent. Control of the bladder and rectum 
is complete. There is a diminution of response to the faradic and also 
galvanic currents in the affected muscles and in certain instances this 
may obtain in muscles which are apparently normal. 

The course is an exceedingly slow one and usually not continuously 
progressive. In this regard it differs greatly from the allied conditions. 
There may be remissions of such length that cure may be said to have 
occurred. The disease seldom results in death and many patients live 
an active, self-supporting life for years. A return of the affect e. I 
parts to a normal condition is impossible even though complete arresi 
may take place. 

The nerves in the peroneal type of muscular atrophy arc almost 



824 DISEASES OF THE NERVOUS SYSTEM 

always the seat of a marked interstitial growth. Associated with the 
neural change is a degeneration of the posterior columns of the cord 
and a marked atrophy of the muscles involved. Here, as in all these 
allied diseases, exceptions may be found in a preponderant alter- 
ation in the cord and muscles and an almost complete escape of the 
nerves. 

No known treatment arrests the prognosis of the disease. Electricity, 
massage and baths may assist in retaining muscular function. Ortho- 
pedic treatment (tenotomy, braces, etc.) is of marked aid in preserving 
the ability to walk. 

Muscular Dystrophies. — There are certain well established facts in 
regard to the muscular dystrophies. The changes are primarily in the 
muscles. They are not dependent upon lesions of the nerves or the cord 
even though secondary degenerations may be present in those situations. 
While isolated cases are here and there encountered, muscular dystrophies 
are family diseases. They affect boys rather more often than girls. What 
it is that determines the progressive wasting of the muscles is quite un- 
known. It appears to be an inherent weakness of the muscular system, 
an inability of the muscles to carry on the fight for existence. They 
fail to survive as various parts of the nervous system may fail. 

The lesions of muscular dystrophy are essentially the same, no 
matter what the type. The individual muscle fibers waste. They become 
round instead of polygonal and eventually they disappear, leaving the 
sarcolemma sheath, with greatly increased nuclei. Certain .of the fibers 
may actually hypertrophy to several times the size of the normal fiber, 
but this is only a temporary process. Eventually the hypertrophic fibers 
share in the general atrophy. Replacement of the muscle fibers by 
connective tissue occurs as the atrophy goes on, and coincident with the 
muscular atrophy a deposition of fat takes place in the muscle. This 
may largely compensate in amount for the atrophy of true muscular 
substance so that the diminution in size of the whole muscle may be very 
gradual. This deposition of fat may even be excessive and thus the 
pseudo-hypertrophy is caused. Upon the relative amounts of the mus- 
cular tissue, connective tissue and fat, depends the appearance of the 
muscles as a whole. They are lighter in color than normal, perhaps even 
yellow and soft. Eventually, the fat largely disappears and only firm, 
fibrous and contracted strands of connective tissue are left. 

Pseudo-Hypertrophic Paralysis. — This is the most frequent and 
best-known variety of the muscular dystrophies. The symptoms as a 
rule come on early in childhood, nearly always before the tenth year, 
and generally between the second and seventh. The earlier symptoms 
relate to a general weakness of the lower extremities, which is accom- 
panied by a marked increase in the size of certain muscular groups. 



PROGRESSIVE MUSCULAR WASTING 



825 



usually those of the calves, but sometimes more of the thighs or the 
gluteal regions. The enlargement may affect almost any muscular group 
of the lower extremity. Children walk unsteadily, and fall very easily. 
They have special difficulty in rising from the floor and in mounting 
stairs. The method of rising in well-advanced cases is quite character- 
istic; the patient lifts his body until he 
touches the floor only with the hands 
and feet; then he proceeds to "climb up 
himself" by putting first one hand upon 
the knee, and then the other, gradually 
moving his hands higher and higher up 
the thighs until the erect position is at- 
tained. This is seen in many of the 
cases, but not in all. 

Most of these patients exhibit, while 
standing, a marked degree of lumbar 
lordosis, due to the weakness of the ex- 
tensors of the hip and later of the mus- 
cles of the back. They stand with their 
shoulders far back. This is well shown 
in Fig. 127. The patient may be so 
weak upon his legs that the slightest 
touch will cause him to fall, even with 
his apparently immense muscular devel- 
opment. The small muscles are gener- 
ally weaker than those which are en- 
larged. 

With the progress of the disease, the 
muscles of the arms and shoulders be- 
come involved. Some of these atrophy 
;it once, others may exhibit pseudo- 
hypertrophy for a time. The infra- 
spinatus is the most frequently enlarged, 
next the supraspinatus and the deltoid. 
The pectorals and latissimus dorsi are 
never enlarged but are generally marked- 
ly wasted. The weakness of the shoulder. 
muscles makes the characteristic diffi- 
culty in picking the child up by graspin| 
slip through the hands. The rhomboids and the levator 
nlae, the biceps and the triceps gradually are involved, and Inter in the 
disease there is such marked atrophy with corresponding weakness of all 
the affected groups thai the patienl may be unable to walk or even Btand, 




Fig. 127. — Muscular Pseudo-hy- 
pertrophy. Showing to a mod- 
erate degree the large calves and 
gluteal regions with a marked 
lordosis. (From a photograph 
by Dr. M. A. Starr.) 



him under the arm; 



They 



angulae scap 



826 DISEASES OF THE NERVOUS SYSTEM 

and is absolutely helpless with the exception of the use of his hands. 
The knee-jerk is at first normal, but gradually diminishes until it is 
finally lost. The electrical reactions are normal until marked wasting 
occurs, when there is a lessened response to faradism and galvanism, but 
never the reaction of degeneration. There are no fibrillary contractions, 
and no sensory disturbances. The progress of the disease is generally 
slow, and sometimes irregular. It is often more rapid in early childhood, 
and slower after puberty. Many of these children, though apparently 
bright, are distinctly below the average for their ages. 

The prognosis is grave, most patients dying in from five to ten 
years. Death seldom results from the disease itself, but rather from 
some intercurrent disease, especially of the lungs. Nothing can be done 
to stay the course of muscular dystrophy. The diagnosis is generally easy 
from the apparent hypertrophy and actual weakness of the muscular 
groups. The disease is incurable. 

The Juvenile Form of Muscular Atrophy (Erb's Type). — This is 
much less frequent than the form just described and usually begins 
somewhat later in life, between the tenth and sixteenth years. It is 
characterized by progressive wasting of certain muscular groups, espe- 
cially those about the shoulders and pelvis, and hypertrophy of other 
groups. Of the shoulder and upper extremity, the muscles affected are 
the pectorals, the trapezius, the latissimus dorsi, the serrati, the rhomboi- 
dei, the muscles of the upper arm and the subscapularis. The deltoid, 
infraspinatus and supraspinatus for a long time escape, and may be 
hypertrophied. The hand and forearm are not involved. In the lower 
extremity, the muscles of the pelvis, thighs, and gluteal regions are 
affected, while those of the leg and foot escape until late in the disease. 
Weakness and atrophy of the muscles of the back cause lordosis of 
great severity. In this disease there are no fibrillary contractions, no 
reaction of degeneration, and no sensory disturbances. The course 
and result of this form are essentially the same as in the preceding 
variety. It is now regarded as the same disease pathologically, the 
only difference being that of localization. In the terminal stages dif- 
ferentiation may be impossible and mixed cases that demonstrate from 
the beginning the predominant characteristics of both types are 
encountered. 

Landouzy-Dejerine Type. — In this, wasting begins in the muscles 
of the face; the lips are thickened and weakened. They cannot be 
firmly closed, but all the rest of the facial muscles are markedly atro- 
phied, giving a peculiar expression to the mouth known as "the tapir 
mouth." Speech may be greatly interfered with but the muscles of 
mastication and deglutition are not affected. This serves to differen- 
tiate the disease from bulbar paralysis. Later, the atrophy extends to 



CONGENITAL MYATONIA 827 

the shoulders and arms, but does not involve the supraspinatus or 
infraspinatus, or the flexors of the hand and forearm. This type is 
sometimes described as beginning in the shoulders, or even in the legs. 
The description therefore corresponds to the juvenile form of Erb, 
with the addition of the facial symptoms, and it is undoubtedly a variety 
of the same disease. 

CONGENITAL MYATONIA 

(Congenital Amyotonia — Oppenheim's Disease) 

This disease was first described by Oppenheim in 1900. Its cause 
is unknown. The symptoms are usually noticed in the early months, 
sometimes very soon after birth. In some cases it has been observed 
even during pregnancy that fetal movements were less vigorous than 
usual. There is a general flaccid paralysis. That of the lower extremities 
is usually complete; but in the upper extremities feeble movements of 
hands or arms may be present. The intercostal muscles and those of 
the neck are usually but not always involved. The diaphragm and 
all the muscles supplied by the cranial nerves escape. There is no 
ocular or facial paralysis. . 

In the well-marked cases the child lies completely helpless and 
motionless; the knee jerks are absent; but sensation is not affected and 
the mentality is normal. The electrical reactions are feeble or even 
may be absent. Owing to involvement of the intercostals the respira- 
tion is usually labored, panting and diaphragmatic in character. 
Secretions accumulate in the pharynx and air passages and choking 
attacks often occur. These may result in fatal asphyxia, or in aspira- 
tion pneumonia. The pulse is normal and regular. There are appar- 
ently no subjective symptoms. The infants are usually well nourished 
and may even be very fat. In those who live for several months or 
years the intelligence is apparently normal and control over the sphinc- 
ters complete. Deformities of the chest are often produced as a conse- 
quence of the paralysis of the respiratory muscles. 

Besides the marked form of the disease, to which the above description 
refers, it, is now recognized that myatonia may occur in all degrees of 
severity. In the mild form there may be only very great weakness and 
atony of the muscles. The ability to hold up the head or to walk may 
then be greatly delayed though the intelligence may be quite normal. 
These cases are often confounded with rickets; but the weakness in 
myatonia is permanent. Owing to the greater involvement of some mus- 
cular groups, contractions of opposing groups may occur. This may 
lead to confusion with poliomyelitis. The milder forms of myatonia 



828 DISEASES OF THE NERVOUS SYSTEM 

may be readily overlooked and may cause but little interference with 
function. Between these and the severe forms of the disease there are 
seen all degrees of muscular weakness. 

The lesions are chiefly in the muscles, which show great atrophy 
and degeneration. They may waste to fibrous cords or may largely be 
replaced by connective tissue and fat. In several of the cases the cells 
of the anterior horns of the cord have been found reduced in number, 
sometimes almost absent, and the anterior nerve roots atrophic. The 
brain is normal. The nervous lesions are to be regarded as a failure of 
development rather than a degeneration. It is believed by some that 
they are the primary condition, the lack of muscular development being 
the result of deficient innervation. 

Many of these infants suffering from this disease die in the first 
year, most frequently from bronchopneumonia to which they are espe- 
cially predisposed by reason of the condition of the respiratory muscles. 
The duration of the mild forms of the disease is indefinite. We have 
seen a few older children and young adults with this form of the disease. 
In some cases a slight improvement has taken place; but no cures have 
been reported. The condition is not influenced by treatment. The dis- 
ease usually either remains stationary or very slowly progresses, the child 
dying of some intercurrent disease. 



CHAPTER V 

DISEASES OF THE PERIPHERAL NERVES 

MULTIPLE NEURITIS 

Under the term multiple neuritis are included those cases in which 
several nerves are involved in an inflammatory process, which may at 
times be general. In its distribution multiple neuritis is usually sym- 
metrical, but it is not necessarily so. 

Etiology. — The chief cause of multiple neuritis in children is diph- 
theria, although it is occasionally seen after other infectious diseases, 
especially malaria, typhoid or scarlet fever, measles, and mumps. In 
diphtheria the inflammation is due to the direct action of the toxins 
upon the nerve structures, since it can be induced in animals by injecting 
toxins into the circulation. There is little doubt that in all infectious 
diseases the inflammation is excited in a similar way. The metallic 
poisons, lead and arsenic, are rarely the cause of multiple neuritis in 
early life, and the same is true of alcohol, although a marked case from 



MULTIPLE NEURITIS 820 

this cause has come under our observation in a child only three years 
old. 1 Lastly, there are cases in which the cause assigned is simply 
exposure to cold — those classed as rheumatic. 

Lesions. — Almost any nerves in the body may be affected, although 
the distribution varies somewhat with the cause of the disease. The 
musculo-spiral and the anterior tibial nerves are most frequently in- 
volved, but the inflammation may affect any of the spinal nerves, includ- 
ing the phrenic, and occasionally the cranial nerves, especially the pneu- 
mogastric, hypoglossal, oculomotor, and abducens. Several nerves in 
different parts of the body are usually affected, the lesion being in most 
cases symmetrical. 

The affected nerve is sometimes red and swollen, owing to acute 
congestion and edema or to a sero-fibrinous exudation. In other cases the 
changes are almost entirely degenerative. The miscroscope shows the 
changes sometimes to be chiefly interstitial and sometimes chiefly paren- 
chymatous. There is an exudation of cells into the sheath, between the 
sheath and the nerve fibers, and even between the nerve fibers themselves. 
The myelin breaks up into granules, and in places may completely dis- 
appear. The late changes are those of subacute or chronic degeneration 
of the nerve fibers. 

With these changes in the nerves there are associated, in some cases, 
inflammatory and degenerative changes in the ganglion cells of the 
spinal cord, although they are much less severe than are the lesions in 

1 This case was in many respects a remarkable one. The boy completely 
emptied a decanter containing twelve ounces of whisky, but almost immediately 
vomited the greater part of it. He soon after showed the symptoms of alcoholic 
intoxication, and in a few hours became comatose, in which condition he con- 
tinued for twelve hours. After this he gradually lost power in his legs, and at 
the end of a week was unable to walk at all. He had convulsions, and after this 
there developed the usual symptoms of meningitis at the convexity, with which 
he was admitted to the Babies' Hospital, three weeks after drinking the whisky. 
The child was then unconscious and there was present incomplete paralysis, af- 
fecting all four extremities, with anj|thesia of the arms. The active inflamma- 
tory symptoms continued for six weeks longer, during which time there were 
repeated convulsions, continuous stupor, fever, gradually increasing deformities, 
marked atrophy, loss of reflexes, and great diminution in the faradic contractility 
of all the paralyzed muscles; in the thighs, left leg, and abdominal muscles there 
were no responses to a strong current, but there was nowhere the reaction of 
degeneration. The child was at death's door for three or four weeks. Three 
months after the attack the first signs of improvement were observed in the 
cerebral symptoms. Shortly afterward he began to use his hands, and at the 
end of six weeks he was walking alone and talking freely. The improvement w i- 
very rapid, and eight weeks from the date of the first change for the better, and 
five months from the time of taking the whisky, he was as well as ever. The 
diagnosis was multiple alcoholic neuritis, with a convexity meningitis. (Fig. 128 
is from a photograph taken while the symptoms were at their height.) 
28 



830 DISEASES OF THE NERVOUS SYSTEM 

the nerves. However, they were once regarded as the explanation of 
some of these cases, particularly of diphtheritic paralysis. 

Symptoms. — The onset of multiple neuritis is in most cases a gradual 
one, it being usually from two to four weeks before the paralysis 
reaches its height. Very exceptionally the onset may be abrupt, with 
fever, and marked paralysis in a few days. It is characteristic of this 
disease that both motor and sensory symptoms are present, and that they 
are the same in their distribution. The symptoms are usually symmet- 
rical. There is first noticed a general weakness in the affected muscles, 
which slowly increases to complete paralysis. As the extensor groups 
of the hands and feet are apt to be affected, there are wrist-drop and 
foot-drop (Fig. 128). The paralysis may begin in the feet and hands, 





'::':;. 

Fig. 128. — Alcoholic Neuritis, showing Characteristic Dropping op the Feet. 
This position of the lower extremities was maintained for over a month. Boy three 
years old. 

and gradually extend until it involves not only the four extremities, but 
even the muscles of the trunk and the neck, although this is rare. The 
child may then be absolutely helpless, unable to sit up, or even to support 
his head. In such cases the head seems loosely attached to the body, and 
rolls about on the shoulders like a ball. Weakness of the spinal muscles 
leads to deformities (Fig. 129) which may be mistaken for Pott's 
disease, even by experienced observers. In most of the muscular groups 
the paralysis is incomplete. The symptoms which relate to the phrenic 
and the cranial nerves will be described with Diphtheritic Paralysis, for 
they are rarely seen in any other form. It is characteristic of multiple 
neuritis that the bladder and rectum escape. 

The sensory symptoms are marked only in the early stage of the 
disease, while the paralysis is increasing; they improve so much more 
rapidly than the motor symptoms, that they may be altogether wanting 
at the time that the paralysis is at its height. In some cases they arc 
so slight as to be overlooked. There is usually pain along the course 



MULTIPLE NEURITIS 



831 



of the affected nerves, which is sharp and neuralgic in character, and 
generally associated with acute tenderness of the nerve trunks and of 
the muscles. Often there is a general hyperesthesia in the early part 
of the attack, followed by partial anesthesia. The sensations of touch, 
pain, temperature, and the muscular sense are all about equally affected. 

Ataxia is not uncommon, and may 
be a more striking symptom than the loss 
of power. All the reflexes are diminished 
or lost, especially the knee-jerk, as the 
legs are usually most affected. Some- 
times, particularly after diphtheria, 
there is loss of the knee-jerk, when there 
is no other symptom of neuritis. In the 
severe cases muscular tremor is fre- 
quently present. 

Atrophy is a prominent symptom of 
neuritis, and it is evident early in the 
disease, often being quite as rapid as in 
poliomyelitis. The electrical reactions 
are altered — every grade of reduction in 
the responses being seen, from a slight 
diminution in the reaction to faradism 
to the complete reaction of degeneration. 
Vasomotor symptoms, such as edema of 
the affected parts, glossiness of the skin, 
etc., are often present. Deformities 
from muscular contraction occur early; 
they may be severe, and in some cases, 
permanent. 

Course and Prognosis. — The usual 
course of the disease is for the symptoms 
gradually to increase for three or four 
weeks and then improve, sometimes rap- 
idly, but more often slowly, the case 
usually going on to complete recovery in 
the course of a few months. Exception- 
ally the paralysis may be permanent. The sensory symptoms always dis- 
appear before the motor ones. Multiple neuritis may prove fatal, from 
paralysis of the hear! or the muscles of respiration, or death may be due 
to asphyxia from the entrance of food or foreign bodies into the air 
passages, owing to anesthesia of the epiglottis and paralysis of the mus- 
cles of deglutition. Death sometimes follows from complications, espe- 
cially pneumonia. The electrical reactions are of much prognostic value 




Fig. 129. — Multiple Neuritis 
after Diphtheria in a Child 
Four Years Old. The posi- 
tion of the head and spine is due 
to partial paralysis of the trunk 
and neck. The legs were also 
affected. 



832 DISEASES OF THE NERVOUS SYSTEM 

in regard to the persistence of the paralysis. If the reaction of degenera- 
tion is present the paralysis is certain to last many months, and some 
muscles are sure to be permanently affected. Where there is simply a 
diminution in the faradic responses, even though accompanied by 
marked atrophy, complete recovery may be expected, although it is often 
slow. 

Diagnosis. — The diagnostic features of multiple neuritis are the com- 
bination of motor and sensory symptoms with the same distribution, the 
occurrence of atrophy, and the diminution in the electrical responses, 
even the reaction of degeneration. The gradual onset and the wide- 
spread distribution of the paralysis are also characteristic. If all four 
extremities are paralyzed, it is altogether the most probable disease ; and 
if to this is added paralysis of the neck and spinal muscles, the diagnosis 
is almost certain. The facts that the paralysis is often incomplete, and 
that it involves parts distant from each other, are also important. 
Neuritis may be mistaken for poliomyelitis, for Landry's paralysis, or 
for Pott's paraplegia; an important diagnostic point from the last men- 
tioned is the condition of the reflexes — being greatly exaggerated in 
Pott's paraplegia, while they are diminished or lost in multiple 
neuritis. 

Treatment. — As this disease tends in the great majority of cases to 
spontaneous recovery, it is difficult to estimate the value of any method 
of treatment. Causes, such as lead, arsenic, alcohol, and malaria, are to 
be sought and removed as the first step. During the acute stage the pain 
may be so severe as to require relief, which is best accomplished by the 
application of heat. In using counter-irritation much care is necessary, 
for troublesome ulceration may follow. After the acute stage has passed, 
or at the end of three or four weeks, electricity should be begun, faradism 
being used if the muscles respond to a moderate current, otherwise gal- 
vanism. This should be continued daily until recovery. Strychnin is 
much used in these cases, but it is doubtful whether it has any specific 
influence, although as a tonic it is valuable. Other tonics, such as iron, 
quinin, and cod-liver oil. should also be given. Massage is also bene- 
ficial. The special treatment of cardiac and respiratory paralysis will be 
discussed in the following article. 



DIPHTHERITIC PARALYSIS 

This is not only the most frequent variety of multiple neuritis, bul 
it has some peculiarities which make a separate consideration of it 
desirable. 

Frequency. — According to the statistics of various observers, paraly- 



DIPHTHERITIC PARALYSIS 833 

sis. including all varieties, occurs after diphtheria in from 5 to 15 per 
cent of the eases. Sanne gives 11 per cent in 2,448 cases; Lennox 
Browne, 14 per cent in 1,000 cases (in neither of these groups did the 
patients receive antitoxin) ; the Report of the Collective Investigation 
by the American Pediatric Society, 9.7 per cent of 3.384 cases which 
were treated by antitoxin. The most recent figures are those of J. D. 
Bolleston. He encountered some form of paralysis in 20.7 per cent 
of 2,300 cases, all personally observed by him. 

There can be little doubt that since the introduction of treatment 
with antitoxin more cases of post-diphtheritic paralysis are observed 
than in the pre-antitoxin days. The undoubted explanation of the fre- 
quency with which paralysis is seen after antitoxin treatment is that 
patients now live long enough to develop paralysis, when without anti- 
toxin the same patients would have died during the early stage of the 
disease. 

Xeuritis is more likely to follow severe than mild cases. Its occur- 
rence after some very mild attacks shows how great is the susceptibility 
of the nervous tissues to the action of the poison. But the great deter- 
mining factor is the duration of the action of unneutralized toxin upon 
the nerves. The frequency of neuritis is in direct relation to the 
length of time elapsing before the administration of antitoxin. Bolles- 
ton's figures upon this point are illuminating. When antitoxin was 
given on the first day of the disease, 3.6 per cent of the cases subse- 
quently developed paralysis; on the second day, 14.09 per cent; on the 
third day, 21.4 per cent; on the fourth day. 2G.9 per cent; on the 
fifth day. 26.3 per cent; on the sixth day, 27.1 per cent. Xo better 
proof of the protection of the nervous system by antitoxin can be 
adduced. 

Time of Occurrence. — During the second week, and sometimes even 
during the latter part of the first week, the early paralysis occurs, usu- 
ally affecting the palate. The most frequent and most characteristic 
paralysis — that affecting the throat, eyes, extremities, and respiration — 
begins at a later period, usually not before four or five weeks after the 
throat has cleared off, and sometimes even later than this. 

Extent and Distribution of the Paralysis. — Ross gives the following 
statistics of 171 collected cases of diphtheritic paralysis: palate affected 
in 128; eves in 77. in ."> 1 of which the muscles of accommodation were 
involved; lower extremities in 1 1 ."> : upper extremities in (ii»; trunk or 
neck in 58; muscles of respiration in 33. In the 11^ <ases reported 
by Rolleston the paralysis was distributed as follows: palate. 331 (74 
per cent) ; ciliary muscles, 236 (53 per cenl ) ; extra-ocular muscles, N " 
(is per cent): pharynx. :'><; (11 per cent); diaphragm, lii (3.6 per 
cent). 



834 DISEASES OF THE NERVOUS SYSTEM 

Symptoms. — In the great majority of cases the throat is affected, and 
usually the paralysis is first noticed there. It may involve the palate 
alone, or the muscles of the pharynx or larynx in addition. The muscles 
of the extremities or of the eye are often next attacked. In severe cases 
there may also be involved the muscles of the trunk and neck, and some- 
times the diaphragm. Paralysis of the throat and diaphragm distin- 
guishes diphtheritic paralysis from other forms of multiple neuritis. 
Whatever the extent or situation of the paralysis, the knee-jerk is nearly 
always lost. The symptoms in the extremities and the trunk do not differ 
from those of multiple neuritis from other causes. The throat paralysis 
shows itself by a nasal voice and by regurgitation of fluids through the 
nose, sometimes by difficulty in swallowing or by the entrance of food 
into the larynx, owing to anesthesia of the epiglottis and paralysis of 
the muscles of deglutition. There may be difficulty in protruding the 
tongue or in articulation. Facial paralysis is rare. On the part of the 
eye there is most frequently seen inability to read, owing to paralysis of 
the muscles of accommodation; there may be dilatation of the pupils, 
rarely strabismus or ptosis. 

Eespiratory paralysis may be due to involvement of the phrenic or 
the intercostal nerves, more frequently the former. Extensive paralysis 
of other parts — the throat, extremities, or trunk — usually precedes. The 
first warning is generally in the form of occasional attacks of dyspnea, 
sometimes accompanied by cough. Gradually these attacks increase in 
frequency and severity. The voice is reduced to a whisper. As the 
diaphragm is usually affected, the breathing is entirely thoracic. The 
respiratory movements are rapid, but irregular, shallow, and ineffectual. 
There is cyanosis, also great subjective as well as objective dyspnea. 
The anxiety, distress, and apprehension of the patient are sometimes 
terrible. There is a constant dread of impending suffocation, and the 
respiratory movements are continued only by the patient's constant 
efforts, otherwise they would cease altogether. After a few hours these 
severe symptoms may subside, to return after a short respite. There 
may be several such attacks during two or three days, in each of which 
death seems imminent. Unfortunately, this is the most frequent termi- 
nation. Of thirty-three such cases collected by Ross, only eight recov- 
ered. Associated with these respiratory symptoms others may be present. 
There may be attacks of abdominal pain, vomiting, and disturbance of 
the heart's action — usually an irregular or intermittent pulse, which 
may be either unnaturally slow or very rapid. In many cases the heart 
continues to beat normally, even though the respiration is so much 
disturbed. 

The premonitory symptoms of cardiac paralysis are an irregular or 
intermittent pulse, often slow, but becoming very rapid from even the 



DIPHTHERITIC PARALYSIS 835 

slightest exertion. It is always weak and compressible. The first sound 
of the heart is feeble and may be reduplicated. Heart block, the disas- 
sociation of auricular and ventricular contraction, has been reported. 
As the symptoms increase there is marked pallor, coldness of the ex- 
tremities, great restlessness, anxiety, precordial distress, aiid perhaps 
orthojmea. Within twenty-four hours from the beginning of such 
symptoms death usually occurs. In other cases it may come suddenly 
without any warning, or with a warning so slight as to be overlooked. 
At such times it often folloAvs some muscular exertion, such as getting 
out of bed, walking across the room, or so slight an effort as sitting up 
suddenly in bed. Fits of temper or other excitement have at times 
produced it. 

It is by no means certain that cardiac paralysis is clue to a lesion 
of the cardiac nerves. Toxic myocarditis appears to be a more im- 
portant factor in producing the fatal result. 

Death in diphtheritic paralysis is usually due either to cardiac or 
respiratory paralysis. Of 171 cases of all varieties collected by Ross, 
45 were fatal, while of Rolleston's 477 cases, 85 were fatal. Death 
can be ascribed to the paralysis in only a small proportion of cases. 
It results usually from cardiac failure which is due to myocarditis 
and not to true neuritis. Cardiac failure was the cause of death 
in 80 of Rolleston's 85 fatal cases. The prognosis of diphtheritic 
paralysis is grave because it indicates that a serious form of diphtheria 
has been present and usually that antitoxin has been given late. The 
pharyngeal and diaphragmatic paralyses may of themselves be fatal. 
the former by causing aspiration pneumonia. 

Treatment. — Cases of paralysis of the trunk or extremities are to be 
managed like others of multiple neuritis. In severe forms of throat 
paralysis feeding by a stomach tube should be employed, on account of 
the danger of the entrance of food into the air passages. II niusi in 
most cases be continued for several days. The tube may be passed 
either through the mouth or the nose. 

The great mortality attending the myocarditis occurring with diph- 
theritic paralysis shows how unsuccessful is treatment in most of the 
cases; still, no doubt there are instances where life may be saved by 
judicious treatment. In cases of threatened cardiac failure the drug 
most to be depended upon is morphin, hypodermically ; this should be 

used every two or three hours in sufficient doses to keep the patient 
under its influence while threatening symptoms are present. The 
patient should be kept absolutely quiet, n<»t even being allowed to turn 
in bed. In respiratory paralysis the general reliance is upon atropiu or 
strychnin used hvpoderniicallv in full doses, and faradization of the respi- 
ratory muscles, particularly the diaphragm. 



836 



DISEASES OF THE NERVOUS SYSTEM 



FACIAL PARALYSIS 




Peripheral paralysis of the face occurring as a result of injury in- 
flicted during delivery has already been described. There remain to be 
considered here cases which arise from causes that operate at a later 
period. The facial nerve may be affected in any one of three situations — 
after its exit from the cranium, in the bony canal, and within the 
cranium. 

In the first situation, the principal cause of neuritis is exposure to 
cold, the "rheumatic" cases; but it occasionally occurs as a complica- 
tion of mumps and disease of the 
lymph glands of this region. The 
nerve is affected just after it has 
escaped from the stylomastoid fora- 
men, and all the branches given off 
beyond its exit are involved. There 
is paralysis of the muscles of the 
forehead, those about the eye, cheek, 
nose, and mouth. The affected side 
of the face is smooth, there is inabil- 
ity to wrinkle the forehead, contract 
the eyebrows, close the eye complete- 
ly, raise the nostril, whistle, or blow. 
The mouth is drawn to the healthy 
- , side (Fig. 130). If the paralysis is 

Fig. 130-Facial Paralysis of Right complete, there may be difficulty in 
Side from Middle-ear Disease in drinking or in articulation. Ill par- 

a Child Two and a. Half Years , • i ■, • ,1 . ' , 

0ld tial paralysis the symptoms may not 

be noticeable while the face is at 
rest. There are no sensory symptoms. The electrical reactions resemble 
those of other forms of neuritis; there is diminution in the response to 
the faradic current, which is more or less marked according to the sever- 
ity of the lesion, and there may be the reaction of degeneration. 

In the bony canal, the facial nerve is usually involved as a result 
of disease of the ear. In children this is much more frequent than 
from the other causes just mentioned. While it occasionally occurs 
with acute otitis, it generally accompanies the chronic form with caries 
of the petrous bone, which in our experience is very often tuberculous. 
In addition to the paralysis there is present or there is a history of a 
discharge from the ear, and generally there is some deafness upon the 
side affected. The facial symptoms are usually the same as in the cases 
first described. However, when the nerve is affected between the stape- 



FACIAL PARALYSIS 837 

dius and the geniculate ganglion, there is a disturbance of the sense 
of taste, and of the secretion of saliva. Facial paralysis may also occur 
as a result of injury to the nerve during the mastoid operation. 

At the base of the brain the trunk of the nerve may be involved in 
cerebral tumor, basilar meningitis, and in fracture of the skull. In 
any of these conditions the auditory nerve also is likely to be affected. 
A not infrequent cause of central paralysis is poliomyelitis. Facial 
paralysis occurs in the cerebral form with hemiplegia, or more com- 
monly it is associated with paralysis from a spinal lesion. Occasionally 
the facial nerve alone may be involved. The whole nerve may be affected 
or only one of its branches. 

Prognosis. — The result is greatly modified by the causes in the differ- 
ent cases. In those which are due to cold, spontaneous recovery usu- 
ally occurs in the course of a few weeks or months. In those depend- 
ing upon disease of the ear, the outlook is not so favorable, and though 
there may be improvement, it is not rare for some paralysis to be 
permanent. In the third group of cases, facial paralysis is only one of 
the symptoms, and the result depends entirely upon the nature of the 
cause. In poliomyelitis the prognosis is good though in some cases a 
certain degree of paralysis may remain. 

Diagnosis. — Facial paralysis is easily recognized. It is important to 
separate the peripheral paralysis from that due to a lesion above the 
pons, as in cases of ordinary hemiplegia. In the latter group only the 
lower half of the face is affected, the muscles of the forehead and those 
about the eye escaping, and the electrical reactions are unchanged. 

Treatment. — This is essentially the same as in other cases of neuritis. 
In cases due to ear disease the primary lesion should receive appropriate 
treatment. 



SECTION VIII 

DISEASES OF BLOOD, LYMPH NODES, DUCTLESS GLANDS, 
BONES, AND JOINTS 

CHAPTER I 
DISEASES OF THE BLObD 

There are several particulars in which the blood of infancy and 
early childhood differs from that of older persons. 

Specific Gravity. — This has no constant relation to the number of 
white or red corpuscles, but varies with the amount of hemoglobin. The 
highest specific gravity is seen in the blood of the newly born. During 
the first two weeks of life it sinks rapidly to its lowest point, where it 
remains until about the end of the second year; after this time it rises 
gradually until about puberty. The average specific gravity during 
childhood is 1.050 to 1.055. 

Hemoglobin. — The percentage of hemoglobin is highest in the blood 
of the newly born, and falls rapidly during the first few days after birth. 
Throughout childhood it is considerably lower than in adult life. The 
hemoglobin is lowest between the third month and the second year; 
after the second year it gradually increases up to puberty. The usual 
range in young children, as measured by the adult standard, is between 
sixty-five and eighty-five per cent, seventy-five per cent being a low Limit 
in healthy children. 

Red Corpuscles. — The Dumber of red corpuscles Is highest in the 
newly horn. At this time it is from t,350,000 to 6,500^000 in each cubic 
millimeter. In infancy it is from t,000,000 to 5,500,000; in later child- 
hood, from 1. 000.000 to 1.500.000 (Ilayem). In size a much greater 
variation is seen in the red cells of the newly bora than in those of older 
children and adults. In the blood of the fetus there are present nucle- 
ated red corpuscles or normoblasts (Plate XII, A). These diminish 
in number toward the end of pregnancy. They are always found in 
the blood of premature infants, hut in infants bom at term they are 
seen only in -mall numbers and disappear after a few days. In later 
infancy their presence is always pathological. 

Normal White Cells. — The following varieties are found in health: 

830 



840 DISEASES OF THE BLOOD 

1. Lymphocytes. — These are small cells about the size of a red blood 
cell. The protoplasm is small in amount, forming merely a narrow rim 
about the nucleus ; it stains with basic dyes rather more deeply than does 
the nucleus. The nucleus is relatively large, is centrally situated, and 
shows at times one or two nucleoli. The protoplasm may have a reticu- 
lar structure. These cells form in adults from twenty-two to twenty- 
five per cent of the white corpuscles, but in young children they are often 
as high as fifty or sixty per cent (Plate XII, B, 10). 

2. Large Mononuclear Leucocytes and Transitional Forms. — These 
cells are two or three times the size of ordinary red cells (Plate XII, D, 
10). The oval nucleus is not so centrally situated as in the lymphocytes, 
and stains feebly but rather more deeply than the protoplasm, which is 
poorly stained by basic dyes. The protoplasm is homogeneous and rela- 
tively large in amount. 

The transitional forms occasionally contain a few feebly staining neu- 
trophilic granules ; their nuclei are bent or curved and stain more deeply. 

3. Polymorphonuclear Neutrophiles. — These are smaller than the 
large lymphocytes (Plate XII, B and C, 8). The nucleus consists of 
three to four parts, usually connected by narrower portions, and stains 
darkly. The protoplasm stains with acid dyes and shows a great num- 
ber of granules Avhich stain only with neutral dyes. In adults these 
cells form about seventy per cent of the white cells; but in children 
they are less numerous, the increase in the lymphocytes being at the 
expense of the neutrophiles. 

1. Eosinophiles. — These are about the same size as the neutrophiles 
(Plate XII, C, 9) ; they have deeply staining nuclei, usually divided 
into two parts. The protoplasm has many large granules that stain 
deeply w r ith acid dyes, and often a narrow outer layer stains more 
deeply than the rest. They form from one to two per cent of the total 
number of white cells. 

5. Mast Cells. — They are only occasionally found, their proportion 
being about 0.5 per cent of the white cells ; they are polymorphonuclear 
cells whose granules stain only with basic dyes, not at all with tri-acid; 
often they are metachromatic (Plate XII, C, 12). 

Pathological White Cells. — Of these there are three principal forms: 

1. Myelocytes, neutrophilic. — They have neutrophilic granules and a 
single rounded nucleus (Plate XII, C, 11). Ehrlich's myelocytes differ 
from those of Cornil in that the cells as a whole are smaller, the nuclei are 
more centrally situated and stain more deeply. 

2. Myelocytes, eosinophilic. — These resemble the polynuclear eosino- 
philes, except for the round, undivided nucleus. 

3. Myelocytes, basophilic. — These are similar to the mast cells, dif- 
fering only in the form of the nucleus. 





c. 



Drawn by Dr. F. C. Wood 



A. Blood of an Eight-Months' Fetus. 
C. von Jaksch's Anemia. 

1. Red cells, normal. 

2. Red cells, normoblasts. 

3. Red cells, megaloblasts. 

4. Red cells, showing mitosis. 

5. Red cells, poikilocytes. 

6. Red cells, granular degeneration. 



B. Simple Anemia. 

D. Acute Lymphatic Leukkmia. 

7. Rod cells, polychromatophilia. 

s. White cells, polynuclear neutrophiles. 

<). White cells, eosinophiles. 

10. White cells, Lymphocytes. 

11. White cells, inyelncv. tea. 

12. White cells, mast cells. 



SECONDARY ANEMIA 841 

These myelocytes all represent immature forms, originating in the 
bone marrow. Pathologically, these may be immature forms of the 
leucocytes, or these may undergo acute or chronic degeneration, with 
swelling and fragmentation, nuclear changes, hydropic degeneration, 
etc. 

The number of leucocytes in the blood of the newly born, according 
tc Rieder, is at birth from 14,200 to 27,400 per cubic millimeter; from 
the second to the fourth day, from 8,700 to 12,400 ; after the fourth day, 
from 12,400 to 14,800. The normal variations in infancy are from 9,000 
to 18,000, and in later childhood from 8,000 to 12,000. 



SECONDARY ANEMIA 

This consists in an impoverishment of the blood, especially the red 
cells, and a corresponding diminution in the specific gravity, and in 
a greater proportional decrease in the amount of hemoglobin. It 
occurs apart from disease of the blood-making organs. Infancy and 
childhood are themselves strong predisposing causes of anemia on 
account of the great demands made upon the blood in the rapid growth 
of the body. 

Etiology. — The causes of anemia embrace a wide range of patho- 
logical conditions. A child born of a delicate mother or of one suffering 
from tuberculosis or syphilis may show a marked anemia at birth. 
It sometimes occurs in the first two or three months of life in a severe 
form without any discoverable cause. It may follow any severe hemor- 
rhage or occur in any of the blood dyscrasiae — purpura, scurvy, etc. 
It accompanies any prolonged infection with or without suppuration, 
also nephritis, many forms of gastro-intestinal disease and malignant 
growths. It is especially marked in general sarcomatosis. Certain of 
the specific infections, notably diphtheria, malaria, tuberculosis and 
rheumatism, produce a marked degree of anemia as one of their effects. 
It is found with great severity with some of the intestinal parasites, 
particularly varieties of the tape-worm and hook-worm. Anemia is at 
times due to mineral poisons — lead, mercury or potassium chlorate. 

Much more frequent in young children than any of the above are 
the anemias due to improper feeding, rickets, and unhygienic surround- 
ings. How important these causes are and how severe a grade of 
anemia may be produced by them, is not usually appreciated. Tin 1 
physician is often led to suspect some serious organic or constitutional 
disease when none exists, and to overlook such common conditions and 
obvious causes as those mentioned. Anemia is seen when lactation is 
unduly prolonged. It is a frequent result of an exclusive diet of milk or 



842 DISEASES OF THE BLOOD 

infant foods into the second or third year. Older children who drink 
tea and coffee and eat largely of indigestible food, pastry, cake, etc., are 
frequently anemic. Lack of fresh air, confinement to overheated rooms 
and the crowding of young children in hospitals and institutions, are 
common and important causes of anemia. 

Symptoms. — Anemic children usually exhibit many symptoms of 
malnutrition. Their tissues are flabby ; they are generally below average 
weight and suffer from digestive disturbances and chronic constipation. 
The associated nervous symptoms are many; headaches, indefinite pains, 
insomnia or disturbed sleep, general irritability and a high degree of 
nervousness. There is easy fatigue, shortness of breath on exertion, 
and sometimes fainting attacks. The peripheral circulation is poor; 
the hands and feet are often cold. The pulse may be slightly irregular. 
Murmurs may be heard over the base of the heart or the large vessels, 
and so loud even in infancy as to be mistaken for organic disease. 
A venous hum may be heard in the neck. Epistaxis is not uncommon. 
There may be enuresis. Edema is rare in older children, but in 
severe anemias of infancy it is sometimes marked. In a certain number 
of cases, even of moderate severity, the spleen is much enlarged. Pallor 
of the skin and mucous membranes is present in most cases, but is not 
an accurate guide as to the degree of anemia. This can only be deter- 
mined by an examination of the blood. 

The Blood. — There is a reduction of the number of red cells and to 
a still greater degree in the hemoglobin. In a case of moderate severity 
the red cells are from 3,500,000 to 4,000,000, and the hemoglobin from 
fifty to sixty per cent. In severe cases the red cells may fall to 2,000,000 
or 2,500,000 or even lower, and the hemoglobin to twenty or thirty 
per cent. These figures are not uncommon. Occasionally there is seen 
a reduction of the hemoglobin to as low as fifteen per cent and of the 
red cells to 1,500,000. The red cells are pale. There is usually poikilo- 
cytosis and anisocytosis ; and, especially in infancy, a few normoblasts 
and megalocytes may be found (Plate XII, B). 

There is generally a slight leucocytosis. The differential count of 
the white cells shows an increase in the lymphocytes, chiefly the small 
variety; the polymorphonuclear cells are relatively reduced in number. 

Prognosis. — The course and termination of anemia depend upon its 
cause. If this is one that can be removed, as in cases depending upon 
improper feeding and surroundings, very rapid improvement often takes 
place and prompt recovery. In the most severe cases death may occur, 
rarely from the anemia, usually from some complicating disease. 

In making a prognosis in a given case the general symptoms and the 
cause of the anemia are much more important than the examination of 
the blood. If the digestive organs are in good condition and good 



CHLOROSIS 



843 



surroundings can be secured, even though the hemoglobin and red cells 
are very greatly reduced, the prognosis is good. But in unfavorable 
surroundings and with a greatly disordered digestion, the outlook is 
more serious. 

Typical blood examinations of a moderate and of a severe case of 
secondary anemia in a young child are as follows : 



Severe Anemia 

Hemoglobin 20 per cent. 

Red blood cells 2,500,000 

White cells 12,000 

Polymorphonuclear 30 per cent. 

Small mononuclear . 45 per cent. 

Large mononuclear 25 per cent. 

Other forms 5 per cent. 



Moderate Anemia 

Hemoglobin 50 per cent. 

Red blood cells 4,000,000 

White cells 10,000 

Polymorphonuclear 40 per cent. 

Small mononuclear 25 per cent 

Large mononuclear 20 per cent. 

Other forms 5 per cent. 



The treatment of all the forms of anemia will be considered together 
at the close of the chapter. 



CHLOROSIS 

Chlorosis usually occurs in young girls about the time of puberty. 
It is characterized by a peculiar greenish-yellow tint of the skin, 
and is not accompanied by emaciation. The changes in the blood 
consist in a very great reduction in the hemoglobin without a corre- 
sponding diminution in the red corpuscles. 

Etiology. — The exact cause of chlorosis is not yet understood. The 
disease rarely occurs in males; it is usually seen in girls between the 
fourteenth and seventeenth years, and more often in blondes than in 
brunettes. Heredity appears to be a factor in some cases. Other causes 
are occupations deleterious to health, such as employment in factories 
or confinement in ill-ventilated rooms; insufficient food or clothing; 
psychical disturbances, like grief, care, or fright; excessive mental or 
physical strain, and disorders of menstruation — although the latter are 
perhaps more frequently a result than a cause of the disease. 

Lesions. — Chlorosis is not a fatal disease. In the few cases with 
chlorosis that have died of other diseases the lesions noted have been 
dilatation of the right heart with hypertrophy of the left ventricle, 
a small aorta, small uterus and ovaries, and occasionally round ulcer of 
the stomach. Under the microscope there may be found a very marked 
degree of fatty degeneration of the heart muscle, and sometimes of the 
inner coat of the blood-vessels. 

Symptoms. — The general symptoms of chlorosis are very much like 
those of simple anemia. There are observed shortness of breath upon 
exercise, palpitation, syncope, attacks of vertigo, disturbances of diges- 



844 DISEASES OF THE BLOOD 

tion, amenorrhea, and almost invariably constipation. The appetite is 
capricious, it being a peculiarity of these patients to crave all sorts of 
indigestible articles. Instead of the usual pallor of anemia, the skin 
has a yellowish-green tint, from which the term "green-sickness" has 
arisen. Occasionally patches of pigmentation are seen. Anemic cardiac 
murmurs may be heard in various situations, most frequently a systolic 
murmur at the base of the heart, and usually loudest over the pulmonic 
area. There may be a venous hum in the neck. In some marked cases 
there is evidence of slight cardiac dilatation, especially of the right 
heart, and there may be hypertrophy of the left ventricle. The pulse is 
weak and soft, edema of the feet is frequent, and sometimes there is 
slight albuminuria. In some cases there is fever. Nervous disturbances, 
such as vague, indefinite pains, attacks of migraine, supra-orbital neu- 
ralgia, various hysterical manifestations, and chorea, are common. Ulcer 
of the stomach is sometimes seen as a complication. 

The Blood. — The specific gravity is reduced in proportion to the loss 
of hemoglobin. The characteristic feature of chlorosis is a loss of hemo- 
globin which is out of proportion to the reduction in the red cells. The 
hemoglobin in an ordinary case is frequently as low as thirty-five or 
forty per cent, while the red cells may be 3,500,000 to 4,000,000, or even 
higher. 

Morphologically the cells are pale with a wide central clear area. 
Poikilocytosis may be present, but is not marked; rarely normoblasts 
may be found. The presence of megalocytes is disputed. The leuco- 
cytes are usually unchanged in number and proportion, but the lympho- 
cytes may be relatively increased. 

Prognosis. — The course of the disease is essentially a chronic one, 
often lasting for a year. Eelapses are quite frequent. These cases 
regularly recover when proper treatment can be carried out. 

Diagnosis. — A probable diagnosis is in most cases easily made from 
the etiology, the functional derangement of the heart, the color of the 
skin, and a positive diagnosis always by an examination of the blood. 

PSEUDO-LEUKEMIC ANEMIA OF INFANCY 
{Von Jaksch Disease) 

This form of anemia was first described by von Jaksch in 1889, 
and is by him believed to be peculiar to infants and young children. 
It is characterized by marked leucocytosis, marked reduction in the 
number of red cells and in the hemoglobin, a great enlargement of the 
spleen, and sometimes a moderate enlargement of the liver and the 
lymphatic glands. This disease is not to be confounded with pseudo- 
leukemia or ITodgkin's disease. 



PSEUDO-LEUKEMIC ANEMIA 845 

The existence of pseudo-leukemic anemia as a distinct disease is 
denied by most authorities on diseases of the blood, who regard it as 
a symptom-complex. They hold that the reported cases can be classed 
either as severe secondary anemia, pernicious anemia, or leukemia. 

Etiology. — Of the cases thus far recorded the majority have been 
between the ages of seven and twelve months. Of twenty cases collected 
by Monti and Berggriin, sixteen showed evidences of rickets and one 
was syphilitic. The exact cause of the disease is still unknown, and 
its essential nature is a matter of some doubt. 

Lesions. — The most characteristic change is found in the spleen, 
which is very much enlarged, often forming an abdominal tumor of 
considerable size. It is firm, hard, and there may be evidences of peri- 
splenitis. The microscope shows a simple hyperplasia. Enlargement of 
the liver is less constant, it being normal in more than half the cases. 
There is no relation between the size of the spleen and that of the liver. 
The hepatic cells are unchanged. Enlargement of the lymph glands has 
been noted in about half the reported cases, the swelling affecting the 
cervical, axillary, or inguinal glands; but it is rarely great. It is due 
to simple hyperplasia. Inconstant changes in the bone-marrow have 
been described. 

Symptoms. — The Blood. — The main features noted are the follow- 
ing (Plate XII, C) : 

The specific gravity is lowered, the usual range being between 1.035 
and 1.044. The reduction of the hemoglobin is very great; in many 
of the cases it has been as low as twenty-five per cent, and in a few below 
twenty per cent. 

The red cells are always diminished; they are frequently below 
2,000,000. There is also great inequality in their size and shape. Nu- 
cleated red cells are found in considerable numbers; as a rule, these are 
chiefly normoblasts, but when the anemia becomes more severe, it is 
usually the megaloblasts that predominate. The leucocytes vary from 
20,000 to 50,000. They may show an increase in the mononuclear or in 
the polymorphonuclear forms. The eosinophiles are usually increased, 
but not to the extent to suggest leukemia. All varieties of cell degenera- 
tion are found. 

The general symptoms of the disease develop slowly and with the 
usual signs of anemia. In some cases the infants continue to be plump 
and well nourished. Pallor is usually very marked. Enlargement of 
the spleen is so great that it can hardly be overlooked if the abdomen is 
examined. The glandular enlargements are not marked, and in many 
cases are wanting altogether. 

The course of the disease is essentially chronic. Cases have been seen 
in which pseudo-leukemia developed from an ordinary severe simple 



846 DISEASES OF THE BLOOD 

anemia in the course of a few weeks. The symptoms and blood changes 
generally come on slowly in the course of weeks or months, and some- 
times remain nearly stationary for as long a period as several months, 
and then slowly improve. In other cases they grow gradually worse. In 
the cases going on to recovery there is noticed improvement in the 
general symptoms coincident with a diminution in the size of the spleen, 
a reduction in the number of leucocytes, an increase in the red cells, the 
hemoglobin, and the specific gravity, and a gradual disappearance of 
the nucleated red cells. 

Prognosis. — In Monti's list of twenty cases, four proved fatal; one 
recovered, in which the proportion of leucocytes to the red cells had 
been one to twelve. The prognosis should be guarded, for, although 
improvement may take place, many patients die from intercurrent 
disease. 

PERNICIOUS ANEMIA 

This is the most severe form of anemia known. Its cause and 
essential nature are as yet very imperfectly understood. It is charac- 
terized by quite uniform blood changes and by the general symptoms 
of a very marked, anemia, and it tends to go on from bad to worse, 
terminating fatally in the great proportion of cases. 

Etiology. — Pernicious anemia, is a rare disease in childhood, and 
especially rare in infancy. Its essential cause is quite unknown. In a 
few instances intestinal parasites, particularly tapeworms, have produced 
in children an anemia indistinguishable from pernicious anemia. 

Lesions. — There is found a very high grade of anemia in all the 
internal organs, fatty degeneration of the heart and blood-vessels, and 
sometimes also of the liver and kidneys, Avith numerous capillary hemor- 
rhages in the various organs. A striking post-mortem change consists 
in the deposit of iron in the hepatic cells. This is found, however, 
with other severe forms of anemia. Its distribution is peculiar and 
unlike that seen in most other diseases. The bone marrow is also 
markedly altered in that the red cells may be of the megaloblastic in- 
stead of the normoblastic type. In aplastic anemia there may be a 
yellow bone marrow instead of the normal red bone marrow of child- 
hood. 

Symptoms. — The Blood. — The specific gravity of the blood in per- 
nicious anemia is constantly and considerably reduced, and its coagula- 
bility is feeble. The hemoglobin is always reduced; usually it is as 
low as from twenty to thirty per cent. The red cells are always much 
diminished in number and to a degree greater than the reduction in 
the hemoglobin. Their number is seldom greater than 2,000,000, and 



PERNICIOUS ANEMIA 847 

frequently less than 1,000,000. Megalocytes are present, often in great 
numbers, and a preponderance of them is regarded essential to the 
diagnosis. Microcytes are rare. It is characteristic of pernicious ane- 
mia that owing to the relatively high hemoglobin content the red cells 
have a high color index and stain well, usually deeper than in normal 
blood. A striking feature of these cases is the presence of extreme 
poikilocytosis. Nucleated red cells are also present, megaloblasts in 
greater numbers than normoblasts. The red cells do not readily collect 
to form rouleaux. The blood platelets are greatly reduced and frequently 
almost absent. 

The total number of leucocytes is markedly diminished, but the lym- 
phocytes may be relatively increased. An occasional myelocyte may be 
found. 

The general symptoms are those of a most intense anemia. There 
is marked pallor of the skin and mucous membranes, with great weak- 
ness and prostration. Various accidental heart murmurs are heard. 
There may be dyspnea. There may or may not be emaciation. The late 
symptoms are hemorrhages from the nose and other mucous membranes, 
subcutaneous ecchymoses with dropsy of the feet and ankles, and some- 
times of the large serous cavities of the body, but without albuminuria. 
In many cases fever is present. This may be so high as to lead to the 
suspicion of some acute infectious process. 

The course of the disease is, as a rule, more rapid than in adults, 
the duration being in most cases but a few months ; it is marked by 
periods of exacerbation and remission. During the exacerbations all the 
symptoms are intensified, and as a rule some fever is present. During 
the remissions marked improvement may take place in all the symptoms 
and an increase in the hemoglobin and red cells occurs. In general, the 
progress of the disease is downward and sometimes the rate is very rapid. 
The only exceptions are the cases in which the disease depends upon 
some intestinal parasite, when improvement and even recovery may 
occur. 

Treatment of the Different Forms of Anemia. — In secondary anemia 
the thing of the first importance is to discover and treat the primary 
condition upon which the anemia depends. In infancy, special atten- 
tion should be given to diet and hygiene. A mixed diet composed of 
fruits, beef juice, eggs and green vegetables should be substituted for 
one consisting mainly or exclusively of milk. Also important is an 
abundant supply of fresh air. The whole manner of life of these 
patients must be carefully studied and managed according to the direc- 
tions laid down in the chapter upon Malnutrition, with which condition, 
especially in infancy, a very large Dumber of these cases are associated. 
The general treatment referred to is often more importanl than the 



848 DISEASES OF THE BLOOD 

administration of the preparations of iron, which, however, should never 
be omitted. 

The preparations of iron especially adapted to infants are the albu- 
minate, bitter wine, sweet wine, saccharated carbonate, malate, and 
citrate. The dose should be regulated according to the age of the child. 
Older children may take the same preparations as adults, especially 
reduced iron and Blaud's pills. Much benefit is seen from combining 
arsenic with iron, or from alternating the two. In addition to these 
remedies, cod-liver oil should be given if the condition of the digestive 
organs will permit. 

In chlorosis more decided results are seen from the use of iron than 
in any other form of anemia. Blaud's pills are here the favorite form 
of administration, and are advantageously combined with small doses 
of mix vomica and aloin to overcome the tendency to constipation. 
Arsenic is useful in these cases also. Great benefit in chlorosis results 
from change of air and change of scene, thus removing the patient 
from all sources of nervous excitement or disturbance. The general con- 
dition, diet, and habits of life should also receive careful attention, 
particularly the condition of the bowels. 

It is important that the administration of iron should be continued 
for some time after the disappearance of all symptoms, on account of 
the tendency to relapse. 

In the pseudo-leuk emic anemia of infants, arsenic is decidedly the 
most valuable drug, but should be given in combination with iron. 
Fowler's solution is the best preparation for infants; the dose should 
rarely be more than one drop, which should be repeated four or five 
times daily after feeding, and continued for a long time. The general 
treatment of these patients is the same as in cases of simple anemia. 
When rickets is present cod-liver oil and phosphorus should be added. 

In pernicious anemia, arsenic offers a much better prospect of im- 
provement than does iron. Beginning with small doses, the amount 
should be gradually increased up to the point of tolerance, very much 
as in cases of chorea. 

In every case of anemia the most careful attention should be given 
to the general condition, particularly guarding against exposure to cold 
and dampness. The feeble circulation of these patients renders them 
peculiarly susceptible. Caution should also be given against much mus- 
cular exercise. 

In cases of secondary anemia transfusion is a remedy of the greatest 
value. In acute anemia following loss of blood its effects are little 
short of marvelous. In the primary anemias and in pernicious anemia its 
effects are much less evident and in the great majority of cases only tem- 
porary improvement is seen. 



LEUKEMIA 84U 



LEUKEMIA 



This is a disease in which the essential feature is a great increase 
in the number of leucocytes, with a moderate reduction in the number of 
red corpuscles, and the presence in the blood of cell forms not found 
in health. 

Etiology. — Leukemia is a rare disease in childhood, but it is seen 
even in early infancy. Its greater frequency in males holds good even 
in childhood. In a small number of cases heredity has been noted. 
Leukemia may follow syphilis, rickets, malaria, or even simple anemia, 
or it may occur apparently as a primary disease in children previously 
healthy. The cause is unknown. 

Lesions. — The essential lesions of leukemia are found in the spleen, 
the lymphatic glands, and the bone-marrow. In some cases the most 
important changes are in the lymphatic glands, giving rise to the 
lymphatic form of leukemia. Any of the external glands of the body 
may be affected — the cervical, axillary, and the inguinal, or the mesen- 
teric, tracheobronchial, the tonsils, and even the lymph nodules of 
the tongue, pharynx, and intestines. The changes in the glands are 
generally those of a simple hyperplasia. The liver is enlarged in most 
of the cases, chiefly from an infiltration with lymphoid tissue, which 
may be diffuse or may occur in patches. Less frequently similar lym- 
phoid masses are seen in other organs. Lesions may be present in 
almost any of the viscera due to secondary infections. In lymphatic 
leukemia the changes in the spleen and marrow may be slight. Changes 
of a severe form in the spleen and marrow are, however, usually seen 
together, giving rise to what is known as the s plena myelogenous form 
of the disease. The spleen is usually enormously enlarged, sometimes 
rilling half the abdominal cavity. In the early stage it is soft, vascular. 
and of a dark-red color; in the late stages it is firm and hard. There 
may be perisplenitis. On section, light-gray patches of lymphoid tissue 
may be seen scattered throughout the organ, and in some instances 
there may be wedge-shaped infarctions. The microscope shows thicken- 
ing of the trabeculae and deposits of lymphoid tissue, especially about 
the arteries. 

Symptoms. — In acute lymphatic leukemia, which in our experience, 
is the most common form of leukemia in early life, the symptoms arc 
so severe and the progress so rapid as to suggest an acute infection. II 
is often preceded by some other infection such as pneumonia, multiple 
abscesses or inflammation of the tonsils. The onset may be abrupi with 
severe symptoms — fever, general and articular pains and great prostra- 
tion, but not much that is definite; or it may be more gradual with only 



850 DISEASES OF THE BLOOD 

local symptoms for several weeks. The swelling of the external lym- 
phatic glands may be the first thing noticed; this is most marked 
usually in the cervical region, but the axillary, inguinal, femoral and 
epitrochlears may also be involved. T he indiv idual olanrl^ nmy ]^ rm 
larger than an almond , but often reach the size of a walnut. There is no 
redness and seldom tenderness. The glandular swelling is usually 
progressive; the spleen and liver soon become large and hemorrhages 
often occur. These may be subcutaneous in the form of small petecKiae 
or larger purpuric areas, or there may be bleeding from the nose, the 
bowels, the bladder, or blood may be vomited. The mouth often is the 
seat of disease resembling scurvy. In fact, these symptoms may domi- 
nate the clinical picture. The gums are much swollen and bleed easily ; 
there may be sloughing in the gums, tonsils or buccal mucous mem- 
brane. The submaxillary glands are swollen and there is much local 
pain and discomfort. The general symptoms at this stage are usually 
severe. The temperature is nearly always somewhat elevated and it 
may be as high as 103° or 104° F. ; there is marked dyspnea and great 
muscular weakness ; the pulse is rapid and feeble and the loss of weight 
usually marked. . 

The blood picture varies greatly in the different cases and in the 
same case at different stages of the disease. The constant feature is 
the great relative increase in the lymphocytes, which usually form from 
90 to 98 per cent of the white cells, and a corresponding reduction in the 
polymorphonuclear cells. The lymphocytes are chiefly of the large 
variety and many of them are degenerated so that they stain with 
difficulty. The total leucocytes in the early stage may not be increased 
and there may even be a leucopenia — 3,000 or 4,000. Sometimes the total 
leucocytes fall greatly toward the end of the disease ; but generally they 
are increased, numbering from 50,000 to 150,000; the red cells are uni- 
formly reduced in number to from 1,000,000 to 3,000,000 and the hemo- 
globin to twenty or thirty per cent or .even lower. The coagulability of 
the blood is diminished. The course of this form of the disease is usually 
rapid. It may last only three or four weeks, and rarely more than two or 
three months. Death is due to hemorrhages, to exhaustion, or to some 
acute intercurrent infection. 

Other cases run a less acute course and may be marked by irregular 
and prolonged attacks of fever which in some cases may be high and last 
for months, but with few other symptoms except enlargement of the 
lymphatic glands. The blood picture varies much from time to time, 
the constant feature being the high percentage of lymphocytes and a 
moderate degree of anemia. The total leukocyte count may be low for 
a long period but a marked relative increase in the lymphocytes is a 
constant feature. The chronic form of lymphatic leukemia does not 



LEUKEMIA 851 

differ greatly from that in the adult but in our experience is very uncom- 
mon in children. 

In the splenomyelogenous form of the disease the progress is usually 
less acute and resembles that seen in the adult, but its course is always 
more rapid in early life. In the case reported by Knox, death occurred 
two weeks after the first symptoms. In most of the cases the early 
symptoms are latent. A sudden and alarming hemorrhage is some- 
times the first thing to call attention to the serious condition. In 
other cases there are only the symptoms of general weakness and anemia. 
Sometimes the splenic tumor is the first thing noticed. In the early 
part of the disease the usual symptoms of anemia are present — digestive 
disturbances, shortness of breath, weak and rapid pulse. Hemorrhages 
may occur as an early or late symptom; they are most frequently from 
the nose, but severe hemorrhages may occur from the stomach, the 
mouth, the intestines, or there may be ecchymoses upon the skin. The 
enlargement of the spleen may be sufficient to form an abdominal 
tumor, so as to attract the attention even of the parents. The swelling 
of the liver is not so great. The lymphatic glands are enlarged only to 
a moderate degree, and in many cases this symptom is absent alto- 
gether. They are painless, movable, and usually several groups are 
affected. 

The late symptoms are dropsy of the feet or general anasarca, 
hemorrhages, diarrhea, headaches, general weakness, and attacks of 
syncope. Fever is quite constant in the late stages of the disease, 
and the temperature may be from 101° to 103° F. The urine may 
contain albumin and casts. Vision is sometimes disturbed by the 
formation of leukemic plaques in the retina. It is rare that there are 
any symptoms referable to the bones, although expansion and tender- 
ness of the flat bones have been observed. 

In the splenomyelogenous form the white cells may be from 100,000 
to 500,000, but, especially under the influence of arsenic, a marked 
temporary diminution may occur, so that their number may be scarcely 
above the normal; both Ehrlich's and CorniPs myelocytes are present, 
and the presence of a large number of these is pathognomonic. The 
number of polymorphonuclear neutrophils is greatly increased, al- 
though their proportion is diminished. The eosinophiles are very much 
increased in number, mononuclear forms being present. The number 
of lymphocytes is increased, but they vary according to the type and 
stage of the disease; basophilic (mast) cells, both mononuclear and poly- 
morphonuclear, are present in considerable number, this being the most 
reliable diagnostic sign. 

Prognosis. — The prognosis of leukemia of all varieties in children is 
very bad, nearly all cases terminating fatally within a tew weeks or 



852 DISEASES OF THE BLOOD 

months from the first definite symptoms. The usual causes of death 
are exhaustion, hemorrhages, and bronchopneumonia. 

Diagnosis. — The general symptoms are likely to be misleading, espe- 
cially fever, dyspnea and prostration. The buccal symptoms frequently 
suggest scurvy. A rapid general enlargement of the external lymphatic 
glands always is suspicious, but without a blood examination, a diagnosis 
is impossible. The chief reliance is to be placed in cases of lymphatic 
leukemia upon the great relative increase in the lymphocytes and reduc- 
tion in the polymorphonuclears more than upon the total number of 
leucocytes ; in other cases the diagnosis rests upon the enormous increase 
in the leucocytes, and especially upon the presence of numerous mast 
cells and neutrophile and eosinophile myelocytes. 

Treatment. — Leukemia is little influenced by treatment. The re- 
ported cures must be taken with some allowance, for most of these were 
published before leukemia was sharply differentiated from simple anemia 
with leukocytosis. Temporary improvement in some cases has followed 
the use of arsenic in full doses. Hemorrhages may be relieved at 
times by calcium lactate. Benzol is often of distinct value in the treat- 
ment of chronic splenomyelogenous leukemia. Its effect is to diminish 
markedly the number of white cells, especially those developed from the 
bone marroAV. The total number of leucocytes may be reduced from a 
hundred thousand or more to less than ten thousand. In giving benzol, 
care should be observed that the reduction does not take place too 
rapidly. As the effect is continuous for a time after the drug is omitted, 
no more should be given after the total number of cells is 15,000 or 
20,000. Benzol may be given in capsules beginning with seven or 
eight grains (gram 0.5) once a day. The close may be increased gradu- 
ally, depending upon its effect, but should not exceed thirty to thirty- 
five grains (gram 2.5). 

Coincident with the fall in the number of white cells there is 
usually a marked increase in the red cells and a great amelioration of 
the patient's condition. This is unfortunately not permanent though 
it may last for many months. Subsequent courses of treatment with 
benzol bring less improvement, or may be without influence. Striking 
improvement has followed transfusion, but this is usually only tem- 
porary. In the great majority of cases the disease goes on to a fatal 
termination in spite of the measures employed. 



HEMOPHILIA 

Hemophilia is an hereditary disease, in which there is a tendency 
to profuse or even uncontrollable bleeding from slight wounds. The 



HEMOPHILIA 853 

hemorrhage may even be spontaneous. Persons so affected are known as 
"bleeders." 

Etiology. — The hereditary tendency of the disease is very strongly 
marked, and it has often been traced through seven or eight generations. 
Males are much more frequently affected than females, the proportion 
being about twelve to one. In the matter of inheritance, the disease 
is most often transmitted through the mother, who, however, usually 
escapes herself. Patients suffering from hemophilia may have nothing- 
else about them that is abnormal. It has no connection with either 
purpura or scurvy. Howell, from his extensive studies upon hemophilia, 
has come to the conclusion that it is due to a relative preponderance of 
antithrombin. The antithrombin may be normal in amount or abso- 
lutely increased but on account of the absolute diminution in the pro- 
thrombin there is always a relative increase in the factors that delay 
the coagulation of blood. 

Symptoms. — The first manifestations of hemophilia are not often 
seen before the second year. The hemorrhages of the newly born have 
no relation to this condition. The discovery of the disease is generally 
quite accidental. The first hemorrhage may be traumatic or spon- 
taneous. In traumatic hemorrhages there may be very severe bleeding 
after so slight a wound as the drawing of a tooth; sometimes a large 
hematoma forms between the muscles as the result of a moderate con- 
tusion. 

The following is the relative frequency of spontaneous hemorrhages 
in 334 cases collected by Grandidier: Bleeding from the nose in 169, 
mouth in 43, intestines in 36, stomach in 15, urethra in 16, lungs in 
17. There may be hemorrhage from the skin or from any mucous 
membrane of the body. The attacks of spontaneous hemorrhage are 
often periodical, and may be accompanied by arthritic symptoms resem- 
bling rheumatism. There are hemorrhages into the joints in some in- 
stances with severe resulting deformity. 

The severity of the hemorrhages varies much in the different cases. 
From a slight wound a patient may bleed until he is exsanguinated, 
and even until death occurs. Such a result from the first hemorrhage, 
however, is rare. In some cases the disposition to bleed is outgrown in 
later life. Grandidier states that, of 152 boys, over one-half died be- 
fore reaching the seventh year. It is striking thai when the disease af- 
fects females there is no tendency to excessive bleeding al menstruation 
or parturition. 

Treatment. — The indications at the time of bleeding are, to arresi 
the hemorrhage by the use of the ordinary surgical means — especially 
compression. Calcium lactate and gelatine may be used as described 
in the hemorrhages of the newly born; but little benefit is to be ex- 



854 DISEASES OF THE BLOOD 

pected from drugs. In all marked cases transfusion should be practiced. 
Its effects are sometimes very striking. In convalescence after attacks 
of hemorrhage, iron and general tonics should be given. In all patients 
who are bleeders everything which might by any means excite hemor- 
rhage should be avoided. 

PURPURA 

The term purpura is used to designate a condition in which there is 
a tendency to spontaneous hemorrhages beneath the skin, from the 
various mucous membranes, and in some cases into the internal organs, 
The term purpura simplex is applied to those cases in which the hemor- 
rhages are limited to the skin; purpura hemorrhagica to those in which 
there is in addition bleeding from the mucous membranes or visceral 
hemorrhages. It is impossible to draw a line sharply between these two 
classes of cases, as the chief difference between them seems to be one of 
degree. Purpura is sometimes known as morbus maculosis or as Werl- 
hofs disease. 

Symptomatic Purpura. — This occurs in quite a variety of conditions, 
the hemorrhages generally being limited to the skin, but not always so. 
These cases may be grouped in the following classes : 

1. Infectious. — This form of purpura is very constantly seen in 
malignant endocarditis, in the hemorrhagic forms of the various erup- 
tive fevers — measles, scarlet fever, variola, vaccinia, and typhus — also in 
epidemic meningitis and occasionally in diphtheria, pyemia, and sep- 
ticemia. The occurrence of hemorrhages in these cases appears to de- 
pend upon an altered condition of the blood-vessels, which is a direct 
result of the infection, and it is a bad prognostic sign. 

2. Cachectic. — Purpura occurs late in the course of many protracted 
and exhausting diseases, especially in infancy. It is most frequently 
met with in bronchopneumonia, empyema, tuberculosis, ileocolitis, in 
both the tuberculous and the simple forms of meningitis, and in malig- 
nant disease. It also occurs from apparently similar causes in several 
of the diseases of the blood, particularly in leukemia and pernicious 
anemia. In most cases of cachectic purpura the hemorrhagic spots are 
small, not very abundant, and occur either upon the abdomen or the 
lower extremities. This form is quite common in hospital practice, and 
is almost invariably indicative of a fatal result. In cachectic purpura 
the hemorrhages are usually limited to the skin. 

3. Toxic. — Certain drugs, such as phosphorus, quinin, potassium 
chlorate, and sometimes others, may in rare cases produce hemorrhages 
when long continued or in large doses. The hemorrhage of jaundice 
may also be considered in this group. 



PURPURA 855 

4. Mechanical hemorrhages, such as those occurring in pertussis or 
epilepsy, are sometimes classed with purpura. In convalescence from 
protracted illness there are sometimes seen, when patients first stand or 
walk, purpuric spots on the lower extremities. They may occur after the 
confinement of a limb in bandages or splints. In both these cases the 
cause is partly mechanical and partly due to the weakened condition of 
the blood-vessels. 

5. Neurotic. — These cases are occasionally seen in diseases of the 
spinal cord and sometimes in hysteria in young adults, but very rarely 
in children. 

Primary Purpura. — This occurs in children of all ages, being not 
uncommon in infancy. Hemorrhages of the newly born have not gener- 
ally been included in this class. The age at which primary purpura is 
most frequently seen is from two to ten years. The sexes are about 
equally affected; of Steffen's 56 cases, 27 were males and 29 females. 
The disease may occur in children who are cachetic, rachitic, or anemic, 
and in those whose surroundings are poor, but it has not, like scurvy, any 
close relation to diet. It may follow any acute disease, being associated 
most frequently with derangements of the stomach and bowels. Quite 
often the disease develops abruptly, without any assignable cause, in chil- 
dren previously healthy. 

Lesions. — The external hemorrhages may occur upon any part of 
the body. There are smaller or larger ecchymoses or an infiltration 
of the tissues with blood, which undergoes gradual absorption with the 
usual changes. With the hemorrhages, various forms of inflammation 
of the skin may be associated, especially erythema and urticaria, with 
sometimes more or less edema. Hemorrhages from the mucous mem- 
branes are more frequent, because of the feebler resistance of the tissues. 
There are seen ecchymoses upon the visible mucous membranes which 
resemble those upon the skin. At autopsy they are occasionally seen 
in the trachea or bronchi, but more often in the digestive tract. In 
the colon, and occasionally in the small intestine, ulcers may be found; 
but they are rarely, if ever, seen in the stomach. They may be super- 
ficial or deep, and have even been known to cause perforation. 

Intracranial hemorrhages are rare, and are usually meningeal. 
These may be sufficient to cause severe symptoms. We have seen an in- 
stance in an infant six months old of extensive meningeal hemorrhage 
covering a large part of the brain. In Steffen's article several such cases 
are mentioned. Pulmonary hemorrhages are not frequent. Ecchymoses 
may be found beneath the pericardium; but endocarditis and pericarditis 
are extremely rare, probably occurring only in the rheumatic cases. The 
spleen is occasionally enlarged, but by no means uniformly so. and it 
may be the seat of hemorrhages. 



856 DISEASES OF THE BLOOD 

While hematuria is one of the most frequent of the visceral hemor- 
rhages, severe nephritis is rare. Acute degeneration of the renal epithe- 
lium of the tubes is quite common. There may be punctiform hemor- 
rhages, and occasionally larger ones beneath the capsule or in the mucous 
membrane of the pelvis of the kidney. The suprarenal capsules may be 
the seat of extensive and even fatal hemorrhage. There may be effusions 
of a sero-sanguineous fluid into any of the large serous cavities, most 
frequently into the peritoneum. The articular lesions of purpura may 
be of a rheumatic character, with which purpura occurs as a complica- 
tion; or there may be hemorrhages into the tissues about the joint, or 
even into the joint itself — usually the knee or elbow. 

The blood shows the changes of secondary anemia — a moderate reduc- 
tion in the hemoglobin and the red corpuscles with occasional irregulari- 
ties in size and the appearance of nucleated red cells. In the most 
severe cases there is a moderate degree of leucocytosis. Duke has demon- 
strated a constant and marked diminution in the blood platelets. 

Pathogenesis. — Why it is that under certain circumstances the blood- 
vessels will not hold their contents, it is difficult to understand. There 
have been described by Cassel, Eiehl, Wilson, and others, changes in the 
small blood-vessels, usually a form of endarteritis, but the lesions are 
not constant. Howell has found no changes in the factors of the blood 
that influence coagulation. They are present in normal quantity and 
proportion. Henoch has suggested the vaso-motor origin of purpura, 
in which there is first a paralytic distention of the small vessels, followed 
by stasis, hemorrhage, or edema. In certain forms, as in malignant 
endocarditis, it is well established that the cause is an infectious throm- 
bosis. Although the bacteriological examinations made thus far in pur- 
pura have not been conclusive, there is reason to believe that infection 
is the essential factor in some forms of the disease, particularly in the 
cases characterized by sudden onset, high temperature, and cerebral 
symptoms, and which run a rapidly fatal course. There are, no doubt, 
now included under this term purpura several diseases quite distinct 
from one another. 

The Clinical Types. — 1. The Ordinary Form. — In the mild cases the 
hemorrhage is confined to the skin (purpura simplex), or it is accom- 
panied by slight bleeding from the mucous membranes. There is usually 
some general indisposition of an indefinite character for a day or two 
before the purpuric spots are noticed; most frequently a disturbance of 
digestion with vomiting, diarrhea, and sometimes slight fever. The 
hemorrhages appear as small petechiae, varying in size from a pin's 
head to a pea, usually first upon the lower extremities. There may be 
only a few widely scattered spots or the body may be covered. The 
color is first a bright red, then purple, gradually fading in the course 



PURPURA 857 

of a few days. New spots come as the old ones disappear, so that the 
amount of eruption may not diminish. They do not disappear upon 
pressure. 

The course of these cases is generally favorable, recovery taking 
place in from one to four weeks. Eelapses are, however, very frequent, 
and such attacks may come at intervals of a few weeks or months for a 
considerable period. One must be guarded in giving an absolutely favor- 
able prognosis in any case of purpura, for it occasionally happens 
that in a patient who for several days has had symptoms of mild pur- 
pura, there suddenly develop those of the most severe type with a rapidly 
fatal termination. 

2. The Severe Form. — Such cases are characterized by hemorrhages 
from the mucous membranes (purpura hemorrhagica) from the outset. 
These may even appear before the spots upon the skin. In severe at- 
tacks the petechial spots are more likely to appear suddenly, and large 
ecchymoses, varying in size from a pea to the palm of the hand, are more 
frequent. There may be bleeding from the nose, gums, mouth, or 
pharynx, and ecchymoses may be seen upon these mucous membranes, 
also upon the conjunctivae. Vomiting of blood and bloody discharges 
from the bowels are quite frequent symptoms. The urine may contain 
enough blood to give it a bright-red color. Less frequently there are 
seen hemorrhages of the retina or choroid and from the female genitals. 
In one of our cases there was almost continuous bleeding from one ear. 
Cutaneous ecchymoses are increased by slight injuries, such as the 
pressure from a bandage or from scratching. Epistaxis may be copious 
enough to necessitate plugging of the nares. The amount of blood vom- 
ited is not often large; its source may be the stomach, the mouth, or the 
pharynx. The blood in the stools is usually dark colored, but there may 
be some bright-red blood even when there are no ulcers present. In one 
of our cases so much blood was lost by the bowels as to produce the symp- 
toms of a very marked cerebral anemia. Jn certain cases the gastro- 
intestinal symptoms are very prominent, and there may be slight icterus. 
The discharge of blood from the stomach or intestine may be accom- 
panied by very severe attacks of colic and tenesmus. In some of these 
eases there are pains and slight swelling of the joints. Renal symptoms 
are generally present. The attacks of abdominal pain with purpura and 
the discharge of blood may come on paroxysmally every few days for a 
period of several weeks. They have been ascribed to thrombosis of the 
intestinal vessels. This is sometimes known as "Henoch's purpura." 

Constitutional symptoms are present in most of the ^mtc i 
There is usually fever, from 101° to 10)5° F.. and sufficienl prostration 
to keep the patient in bed. If the amount of blood losi is large, there 
are the usual svmptoms of severe anemia. The loss of hi I may be 



858 DISEASES OF THE BLOOD 

sufficient to cause death, particularly in infants. Cerebral symptoms 
may depend upon anemia or upon meningeal hemorrhage. They are 
not frequent in this form of the disease. Edema, especially of the face 
and feet, may exist without albuminuria, and albuminuria may be pres- 
ent in cases in which there is no renal hemorrhage. 

In some of the cases beginning with severe general symptoms, and 
occasionally when the onset is mild, the patients after a few days pass 
into a typhoid condition with low delirium, great prostration, weak and 
irregular pulse, dry, cracked tongue, and high temperature. Such cases 
are almost always fatal. They are not to be confounded with ordinary 
typhoid fever complicated by purpura. 

The course varies much in the different cases. It lasts from one to 
six weeks, the symptoms slowly subsiding, but often showing a strong 
tendency to recurrence. The prognosis depends upon the age of the 
patient, the extent of the hemorrhage, and the presence or absence of 
septic symptoms. 

3. The Hyperacute Form (purpura fulminans). — This is a rare 
form, especially in young children. Its development is usually sudden, 
with a chill, vomiting, marked prostration, and high temperature. The 
purpuric spots come out with great rapidity, and in the course of a 
few hours or a day they may be very extensive. In addition to the 
ordinary subcutaneous hemorrhages, bloody vesicles may form upon the 
skin. In many cases the hemorrhages are limited to the skin, the mu- 
cous membranes and the viscera escaping altogether. There is no ten- 
dency to gangrene. Cerebral symptoms are invariably present and usu- 
ally prominent; there may be delirium, dulness, stupor, and finally 
coma. The spleen is apt to be enlarged . The urine is nearly always 
albuminous. This form of purpura has all the characteristics of a gen- 
eral infectious disease, and it is almost invariably fatal. 

4. The Gangrenous Form. — Sloughing is not common in purpura, 
but it is most often seen in the mucous membranes. Osier refers to two 
cases affecting the uvula. We once saw a slough which caused perfora- 
tion of the soft palate. Wickham Legg reports a case with gangrene of 
the prepuce. Gangrene of the skin is even less frequent, although cases 
have been reported even in young children. Charron's patient was only 
three years old, and several others in children are collected in Gimard's 
monograph upon this subject. The gangrene may involve the skin only, 
or the subcutaneous tissues, and even the muscles. It has been seen 
upon the upper and lower extremities, and even upon the face, and may 
extend over quite a large surface. In some of the milder forms of pur- 
pura, gangrene results from some slight injury, such as a blow, the pres- 
sure from a bandage, or, in the nose, from the pressure of a tampon. 
These cases are almost invariably fatal. Those in which the sloughing 



PURPURA 859 

is confined to small areas of the mucous membrane of the mouth often 
recover. 

5. The Rheumatic Form. — The term '"rheumatic purpura" (peliosis 
rheumatica) is applied to cases, not so common in children as in older 
patients, in which subcutaneous hemorrhages, and sometimes bleeding 
from the mucous membranes, are associated with painful joint swell- 
ings. These are to be regarded as cases of rheumatism complicated by 
purpura. The joints most frequently affected are the knee and the 
ankle. The arthritic symptoms are usually less severe than in attacks 
of acute rheumatism. There may be present erythema exudativum or 
erythema nodosum or urticaria. Usually there are throat symptoms 
and fever, and frequently edema of the face and eyelids with albu- 
minuria. The spleen may be enlarged. The usual duration is from one 
to three weeks, and although relapses may occur, the cases usually 
recover. 

Joint symptoms, particularly articular pains, are not infrequent in 
the course of milder attacks of purpura without the febrile symptoms 
mentioned. In severe cases extravasations of blood have been reported 
as occurring in the tissues about the joints, and even in the joints them- 
selves, these being cases of true arthritic purpura. It is probable that 
in the past some cases of scurvy have been included in this group. 

Diagnosis. — The rapid acute cases may be confounded with the hem- 
orrhagic forms of the various eruptive fevers. The ordinary subacute or 
passive forms are chiefly to be differentiated from scurvy. The diag- 
nosis is not difficult, and the mistake need not be made if the essential 
features of scurvy are borne in mind — its dietetic cause, bleeding gums, 
hyperesthesia, and deep rather than subcutaneous hemorrhages which 
are usually near the joints. 

Prognosis. — This depends very much upon the form of the disease. 
Of 128 cases of all varieties occurring in children in Steffen's collection, 
there were 40 deaths. In 12 cases of severe primary purpura reported 
by Gimard, there were 3 deaths and 9 recoveries. Purpura simplex is 
rarely fatal; cases of purpura hemorrhagica usually recover unless 
marked febrile symptoms are present. The forms classed as typhoid, 
gangrenous, and purpura fulminans are almost invariably fatal. The 
tendency to relapse exists in all varieties. 

Treatment. — The treatment of symptomatic purpura should haye 
reference to the cause of the disease. The mild cases of primary pur- 
pura usually recover promptly under a tonic plan of treatment. The 
more severe cases require confinement in bed, absolute quiet, and care to 
avoid exposure and even the slightest injury or extra pressure upon any 
part. Drugs do not seem greatly to influence the course of the disease. 
Those most frequently employed are epinephrin, hydrastis, hamamelis, 



860 DISEASES OF THE LYMPH NODES 

aromatic sulphuric acid, the vegetable acids, ergot, and gallic acid. 
Whether or not it is true, as claimed by some, that all hemorrhagic 
diseases are related to scurvy, the striking improvement seen in this 
disease from the use of fresh fruit and vegetables suggests their employ- 
ment in purpura. In some cases very decided benefit seems to follow 
their use in the acute stage, but more particularly in convalescence. For 
hyperacute and gangrenous cases, little can be done except to treat the 
symptoms. Surgical means of arresting the hemorrhage are rarely suc- 
cessful. In all severe cases transfusion should be tried. 



CHAPTEE II 
DISEASES OF THE LYMPH NODES (LYMPHATIC GLANDS) 

It is characteristic of infancy and childhood that the lymphoid tis- 
sues — tonsils, adenoids, external and internal lymph glands, and many 
smaller lymph nodules throughout the body — are prone to swelling and 
hyperplasia. In robust children infectious processes of the nose, pharynx, 
or bronchi cause acute swelling of the lymph nodes in the neighborhood, 
which rapidly subside when the cause is removed. In others, in whom 
this vulnerability of the lymphoid tissues exists, the hyperplasia in the 
lymph nodes is out of proportion to the exciting cause and continues 
after the cause has ceased to operate. Certain children have at birth an 
excessive development of lymphoid tissue, particularly in the region of 
the throat in the form of enlarged tonsils, adenoid vegetations of the 
pharynx, etc. 

The influence of heredity in. causing this condition is too often seen 
to be passed over as a coincidence. Frequently the parents, during child- 
hood, suffered from the same condition, and often every member of a 
large family of children is affected. They may be in other respects 
healthy, reared amid good surroundings, and show no evidence of any 
other constitutional disease. Any disease in the parents in consequence 
of which children are born with tissues having less than normal re- 
sistance, may be regarded in the light of a remote cause. 

The condition is seen in perfection in children reared in institutions 
and in crowded tenements. It is more common in cities than in the 
country. Anything which produces malnutrition or lowers the general 
vitality of the tissues may be ranked as a cause. Rickets is often asso- 
ciated. 

During infancy, the lymphoid structures most frequently affected are 
those connected with the gastro-enteric and the bronchial mucous mem- 



ANATOMICAL COXXECTIOXS 



SGI 



braiies; in later childhood it is those which are connected with the 
pharynx and tonsils. 

The degree of enlargement of the lymph nodes which is sometimes 
found in the different situations has often led to misinterpretation. 
They have often been connected with pathological conditions or clinical 
symptoms with which they have really nothing to do. 

As age advances we usually see retrograde changes in the different 
groups of glands unless they become the seat of tuberculous infection. 
Those connected with the digestive tract generally begin to diminish 
after the second year, and by the fifth or sixth year the enlargement has 
almost disappeared; while the tonsils, adenoid growths of the pharynx, 
and enlarged cervical glands are usually stationary after the seventh or 
eighth year, and frequently undergo quite a marked atrophy about the 



Name of the 
Group. 



Number and Situation. 



Organs or Areas from which they 
Receive Lymphatics. 



Suboccipi- 
tal. 
Mastoid. 



Parotid. 



Submaxil- 
lary. 

Supra- 
hyoid. 

Superficial 

cervical. 



Deep cervi- 
cal, upper 
set. 



Deep cervi- 
cal, lower 
set. 

Sub-hyoid. 



Retrophar- 
yngeal 



29 



One or two; at nape of 

neck. 
Four or five small ones ; in 

mastoid region. 

Five to ten ; on the surface 
and in the substance of 
the parotid gland. 

Twelve to fifteen; along 
base of jaw, beneath 
cervical fascia. 

One or two; median line be- 
tween chin and hyoid 
bone. 

Five or more; along exter- 
nal jugular vein, beneath 
platysma, but superfi- 
cial to the sternomas- 
toid. 

Ten to sixteen; about bi- 
furcation of common 
carotid and along inter- 
nal jugular vein. They 
are just above upper bor- 
der of the thyroid carti- 
lage and on a level with 
the hyoid bone. 

A chain in the supraclavic- 
ular fossa. 



A few small glands below 
hyoid bone and near me- 
dian line. 

Two small glands in front 
of spine and upon pre- 
vertebral muscles. 



Scalp, posterior portion. 

Receive efferent vessels from group 1 , 
and through them from part of 
scalp. 

Scalp, frontal and parietal portions; 
orbit, posterior part of nasal fossa, 
upper jaw, posterior and upper 
part of pharynx. 

Mouth, lower lip, gums. 



Chin and middle portion of lower lip. 



Auricle, part of scalp, skin of face 
and neck, and some efferent ves- 
sels from groups 1 and 2. 



Lower part of pharynx, larynx, pal- 
ate, tonsils and part of tongue, 
part of nasal fossa, deep muscles of 
head and neck, and from inside the 
cranium. Receive also efferent 
vessels from groups '■'> and 4. 



Connect with axillary group by a 
chain along axillary artery; also 
with glands of mediastinum and 
with groups 7 and 9. 

( Sommunicate with group 8, and may 

connect below with chain of bron- 
chial glands. 
Pharynx and pari of nasal fo- 



862 DISEASES OF THE LYMPH NODES 

time of puberty. The presence of these enlarged lymph nodes and the 
catarrhal condition of the mncous membranes with which they are asso- 
ciated, are important in relation to all acnte infectious diseases which 
affect these mucous membranes. They bring about an increased sus- 
ceptibility to scarlet fever, measles, diphtheria, and most of all to tuber- 
culosis. 

In the table on the preceding page are given the situation and drain- 
age areas of the various groups of lymph nodes of the head and neck 
which play so important a role in infancy and childhood. 



SIMPLE ACUTE ADENITIS 

This is an acute inflammation of the lymph nodes which in infancy 
frequently terminates in suppuration. A certain amount of inflamma- 
tion of the lymph nodes occurs in children in all acute processes affect- 
ing the mucous membranes, especially when they are severe or prolonged. 
Those in connection with the various internal organs are considered with 
the diseases of those organs. Acute inflammation of the external nodes 
is of sufficient frequency to require separate consideration. While this is 
probably always secondary to some pathological process in the skin or 
mucous membranes, the primary condition may be so slight as to be 
overlooked, and the adenitis may be the more important condition or may 
even assume the appearance of a primary disease. It is particularly in 
infants that this is seen, and it depends upon the unusually active ab- 
sorption and upon the susceptibility of the lymphoid tissues at this age. 
The cervical glands are frequently affected, occasionally those of the 
axillary and inguinal regions. 

Etiology. — Acute adenitis occurs in children of all ages in connection 
with diphtheria, scarlet fever, measles, and epidemic catarrh. In such 
cases it is often severe, and after scarlet fever not infrequently terminates 
in suppuration. With the simple acute catarrhal processes of the pharynx 
and rhinopharynx adenitis also occurs, but it is usually mild and rarely 
ends in suppuration. In infancy, on the other hand, acute adenitis 
from simple catarrh is not only very common but often severe, and 
frequently terminates in suppuration. Ulcerative stomatitis, carious 
teeth, eczema of the scalp or traumatism, may excite adenitis in chil- 
dren of all ages. Axillary adenitis may result from vaccination ; ingui- 
nal adenitis, from balanitis or vulvovaginitis. 

Of 109 cases of acute adenitis from our records, not including any 
associated with diphtheria, measles, or scarlet fever, more than three- 
fourths occurred in the first two years, and half of them in the first year 
of life. This susceptibility of infants is very striking. The disease 



SIMPLE ACUTE ADENITIS 



863 



occurs frequently in those who were previously healthy, and often when 
the evidences of disease of the mucous membrane are slight. This is 
true not only of the cases of cervical adenitis, but also of others in which 
the inguinal glands are involved. The inflammation is usually asso- 
ciated with the streptococcus or staphylococcus, occasionally with the 
pneumococcus or influenza bacillus. 

Lesions. — The changes taking place in the glands are acute conges- 
tion, with swelling, edema, and active hyperplasia of the lymphoid ele- 
ments. The process may terminate in resolution or in suppuration 
according to the intensity of the infection and the susceptibility of the 
tissues. When severe enough to cause suppuration, the adenitis is ac- 
companied by considerable inflam- 
mation of the surrounding cellular 
tissue. 

In the series of 109 acute cases 
to which reference has been made, 
not including the specific infectious 
diseases, 96 were cervical, 9 were in- 
guinal, and 4 axillary; sixty-two per 
cent terminated in suppuration, the 
latter being nearly all in infancy. 
Suppurative otitis was present in 
sixteen per cent of the cases. Sup- 
purative retropharyngeal adenitis 
(retropharyngeal abscess) was asso- 
ciated in several cases. 

In infancy the disease is usually 
unilateral, or, if bilateral, the glands 
of one side are more severely affected 
than those of the other. Suppura- 
tion is nearly always of one side, and usually the abscess starts in a 
single gland. 

Symptoms. — The symptoms and course of the adenitis of the specific 
infectious diseases belong to their clinical history. Suppuration is in- 
frequent, except after scarlet fever. 

The typical cases of acute adenitis are those which occur in infancy. 
There are present the symptoms of the original disease — usually acute 
catarrh of the nose or rhinopharynx, mouth, or car, which may nol be 
severe, and sometimes is overlooked. The glands mosi frequently af- 
fected are the deep cervical group. The tumor appears just below the 
angle of the jaw at the anterior border of the sternomastoid muscle 
( Pig». 131). The swelling during the acute catarrh is nol rapid or great. 
but continues after the original process has subsided until it reaches the 




Fig. 131. — Acute Suppurative Ade- 
nitis in an Infant One Year Old. 
Showing the most frequent situation 
of the tumor in the cervical region. 



864 



DISEASES OF THE LYMPH NODES 



size of a walnut or a hen's egg. In the most acute cases there is marked 
inflammation of the periglandular cellular tissue, with pain, tenderness, 
and extra heat. If suppuration occurs, it is generally evident in the 
latter part of the second week, but sometimes it may be as late as the 
third or even the fourth week. In the axillary or inguinal region (Fig. 
132) the symptoms of adenitis are essentially the same as in the neck. 
In the inguinal cases the degree of catarrh of the mucous membrane is 
often very slight. 

Most cases run their course with slight fever and few general symp- 
toms * but in young infants the constitutional symptoms are often severe 
and the physician may be in doubt whether the local process is sufficient 

to explain them. The temperature 
may be from 102° to 104° F. for 
several days, with considerable pros- 
tration, which is much increased if 
there is complicating otitis. After 
suppuration, if freely opened at the 
proper time, the abscess heals rap- 
idly and permanently, a sinus being 
rare. Occasionally the infection ex- 
tends from one gland to another, 
and a succession of these glandular 
abscesses occurs. 

In the non-suppurative cases the 
swelling may be even greater than 
in those which suppurate; but it is 
less diffuse and apparently limited 
to the gland. It subsides slowly in 
the course of from four to eight 
weeks, often leaving a small tumor which may be apparent for several 
months. In susceptible children recurrent attacks of acute inflammation 
may lead to chronic enlargement which may last indefinitely. These 
glands do not become cheesy, except from subsequent tuberculous in- 
fection. 

The acute cases in infancy in which suppuration occurs, appear to 
recover about as promptly and quite as completely as those terminating 
in resolution, although in the former the constitutional symptoms are 
more severe. 

Diagnosis. — This is usually easy if it is remembered that, with the 
exception of the specific infectious diseases, and occasionally local causes 
like eczema of the scalp, carious teeth, etc., acute suppurative adenitis 
is essentially a disease of infancy. It is often mistaken for mumps 
when the swelling is severe, but on close examination there is but little 




Fig. 132. — Acute Suppurative Ade- 
nitis (inguinal) in an Infant 
Three Months Old. 



SIMPLE CHRONIC ADENITIS 865 

resemblance between the conditions. The disease is usually acute, and 
has little in common with the slow suppuration seen in later childhood 
from the breaking down of tuberculous glands. In the occasional cases 
seen in which the disease runs a slower course a diagnosis from the tu- 
berculous form may be aided by a tuberculin test. 

Treatment. — Prophylaxis requires that in all acute catarrhs the 
mucous membrane should be kept as clean as possible by the use of nasal 
or pharyngeal sprays, or by careful syringing with simple solutions like 
Dobell's or Setter's, or a simple saline. 

Ifi the stage of acute inflammation very hot applications or an ice- 
bag may be used for the relief of pain. It is very doubtful whether 
either of these means has much influence in preventing suppuration. If 
abscess forms, incision should be deferred until pointing has taken place. 
If this plan is followed, refilling is rare. A simple incision with proper 
aseptic treatment is all that is required. Curetting may be done if there 
is much broken-down tissue present, but it is not usually necessary. In 
most of the cases the abscess promptly heals and a perfect cure takes 
place. Benefit is seldom seen from painting with iodin or from inunc- 
tions of iodin ointment or the oleate of mercury. If adenitis is second- 
ary to carious teeth, eczema, or ulcerative stomatitis, these conditions 
should receive appropriate treatment. Such cases do not usually sup- 
purate, but subside rapidly when the primary cause is removed. 



SIMPLE CHRONIC ADENITIS 

This consists in a simple hyperplasia of the lymph nodes which is 
non-syphilitic and non-tuberculous. There are considered here only the 
external glands, but those of the cavities of the body are affected in a 
similar way, in diseases of the mucous membranes with which they are 
connected. 

Simple chronic adenitis is not so frequent as the acute form in 
infants, and it is less common after the third year. It may follow one or 
more attacks of acute adenitis, or it may result from subacute or chronic 
inflammations of the skin or of the various mucous membranes, infection 
from which causes the acute form. Chronic enlargement of the glands 
of the neck is very common with adenoids, diseased tonsils and with 
pediculosis of the scalp. 

Symptoms. — The glands upon both sides of the neck are usually 
involved, and more often a group than a single gland. The degree of 
swelling is not generally great, being much less than in acute adenitis. 
and usually less than in the tuberculous form. There are no constitu- 
tional symptoms. Hypertrophy of the tonsil- and adenoid growth- of 



866 DISEASES OF THE LYMPH NODES 

the pharynx are frequently associated. There is no tendency to suppura- 
tion or caseation. The swelling usually increases slowly for one or two 
months, then remains stationary for about the same length of time, after 
which it slowly subsides. A subacute course is more frequent than a 
very chronic one. 

Diagnosis. — These cases are especially to be distinguished from the 
much more frequent cases of tuberculous adenitis. The most important 
points for differentiation are, that they occur most frequently in children 
under two years, a period when tuberculous adenitis is not very com- 
mon; some definite exciting cause is usually present; caseation and sup- 
puration do not occur; the glands do not become adherent to the skin 
or to the deeper tissues; they usually enlarge more rapidly than do the 
non-caseating tuberculous glands; and they are influenced to a greater 
degree by constitutional treatment. The children do not usually respond 
to the tuberculin test. 

Treatment. — Operative measures are not called for in simple ade- 
nitis. Local causes usually found in the pharynx, nasopharynx, or mouth 
should be removed if possible. Pediculosis should be treated. Often 
more can be accomplished by removal to a climate in which the child's 
catarrhal symptoms are relieved than by all else. Little benefit is seen 
from local applications. The most useful internal remedies are, the 
syrup of the iodid of iron (twenty drops three times a day to a child of 
four years), and arsenic (two or three drops of Fowler's solution three 
times a day). Cod-liver oil should be given continuously except during 
warm weather. 

SYPHILITIC ADENITIS 

It is quite rare that a marked degree of glandular enlargement is 
seen as a symptom of hereditary syphilis ; indeed, it is so rare that it is 
often forgotten that chronic multiple glandular enlargements are ever 
due to this disease. In the few examples that have come under our ob- 
servation, this has been a late symptom of hereditary syphilis. The 
glandular enlargements were cervical and multiple, and the degree of 
swelling was often marked. They may be associated with disease of the 
bones or of the mucous membrane of the throat or of the nose, or with- 
out signs of such disease. The diagnosis of syphilis rests upon the asso- 
ciation of other late manifestations of the disease — keratitis, periostitis, 
deformities of the teeth, the Wassermann reaction, and the prompt im- 
provement under antisyphilitic treatment. In their local appearance 
they resemble tuberculous glands. 



TUBERCULOUS ADENITIS 867 

TUBERCULOUS ADENITIS 

(Scrofula) 

Tuberculous disease of the lymph glands of the cavities of the body 
is discussed elsewhere; only that of the external glands is here consid- 
ered. This condition presents some striking peculiarities : it is not com- 
mon in infancy, although one of the most frequent forms of tuberculosis 
in older children; it often exists as the only apparent tuberculous lesion 
in the body. In the great majority of cases it is the cervical glands 
which are affected. 

Etiology.- — The age at which tuberculosis of the cervical lymph 
glands is most often seen is from three to ten years. In tuberculosis in 
infancy, the external glands are not usually involved, while the bronchial 
glands are almost invariably the seat of infection. 

The cervical glands become involved as the result of a descending 
infection from the rhinopharynx or of an ascending infection from the 
bronchial glands. The descending infection is altogether the most com- 
mon one. The tonsils and less commonly the adenoid tissue of the rhino- 
pharynx become tuberculous from the sputum coughed up from the 
lungs or from organisms received into the mouth from outside. From 
the foci in the pharynx the path is direct to the cervical glands. Local 
pathological conditions that affect the tonsils and adenoid tissue and so 
favor the development of tuberculosis are chronic pharyngitis, disease 
of the tonsils and carious teeth. Attacks of grippe, measles and scarlet 
fever, frequently play the role of exciting causes. The question often 
arises whether the process is at first a simple one and later becomes tuber- 
culous, or whether it is a tuberculous one from the beginning. Our own 
belief is that in practically all cases the process is a tuberculous one from 
the outset. 

Of 97 cases of tuberculous adenitis in children studied by Park and 
Krumwiede, 51 showed the human type of bacillus and 46 the bovine 
type. The proportion of cases of bovine infection was much higher in 
children under five years of age than in those who were older ((>1 and 38 
per cent respectively). These findings showing the frequency of bovine 
infection are in striking contrast to those obtained by them in other 
forms of tuberculosis in children and point unmistakably to food or 
mouth infection, most probably tuberculous milk, as a cause. 

Lesions. — It has already been stated that in the greai majority of 
cases the cervical lymph nodes are involved, and generally they are the 
only ones affected. In 155 eases of tuberculous glands in the series re- 
ported by Treves, those of the neck were the seat of disease in 1 15 and 



868 DISEASES OF THE LYMPH NODES 

the only seat in 131; those of the axilla were involved in 17, but alone 
only in 4; the groin in 8, and alone in 6. The nodes first affected are 
most frequently the upper set of the deep cervical group; sometimes, 
however, it is the superficial nodes of the submaxillary, or the parotid 
group, and occasionally the submental or the pre-auricular. The chain 
of deep cervical nodes which is involved, follows the carotid artery, and 
often extends some distance below the clavicle. These deep nodes are 
sometimes connected with the bronchial group, but it is much more fre- 
quent to trace them upward to the tonsils which in a very large propor- 
tion of the cases are tuberculous. 

The process in all tuberculous glands is essentially a chronic one, 
but pathologically the cases may be divided into two groups, correspond- 
ing somewhat to the forms of disease seen in the lungs. In one group 
the process is more rapid, and tends to early caseation and softening; 
the products of inflammation are mainly cellular, and the amount of 
fibrous tissue is small. In another group the course is slower, and fibrous 
tissue predominates, caseation and softening being late or absent. 

In the first group the glands in the early stage are swollen, of a pale 
pink color, and homogeneous; later they become more firm, and show, 
as the first gross evidence of tuberculous deposits, small grayish-white 
spots, which are generally numerous and scattered- through the affected 
gland; these spots enlarge, and may coalesce to form one large gray 
mass, involving nearly the whole gland. Subsequently there is caseation 
and then softening, usually beginning in the center of the caseous area. 
Inflammation within the gland is followed by that of the surrounding 
tissues, which may result in adhesions or in the formation of a peri-glan- 
dular abscess. The first change in the gland is the production of epithe- 
lioid and giant cells, about which there is a zone of small round cells; 
cheesy degeneration then begins in the center. The caseous masses may 
become encapsulated by the production about them of fibrous tissue; or 
softening may occur at one or more foci, and an abscess form. Such an 
abscess contains curdy material, but very little true pus, the contents 
being chiefly detritus from the broken-down node. Tubercle bacilli are 
usually more numerous in the early stages of the process, but are often 
difficult of detection in broken-down tissues, and the curdy pus is some- 
times sterile. As the glands soften, the process gradually extends from 
the center to the surface, and they become adherent to the surrounding 
structures — blood-vessels, nerves, or the fascia — they fuse together and 
form large knotty masses, and when they ultimately break down they 
lead to the formation of an abscess in the cellular tissue, finally involv- 
ing the skin. In the form of suppuration which occurs in and about 
tuberculous nodes, an important part is often played by other bacteria, 
usually the staphylococcus or the streptococcus. 



TUBERCULOUS ADENITIS 869 

In the second group of cases, where the process goes forward more 
slowly, the changes are not quite the same, the essential difference being 
that the amount of fibrous tissue is much greater. These nodes are not 
so vascular; they are tough and hard, appearing like small fibrous 
tumors. The capsules are greatly thickened, and under the microscope 
is seen fibrous tissue arranged in concentric layers, often inclosing small 
caseous masses. These nodes less frequently form adhesions to the sur- 
rounding tissues, and consequently are freely movable, while suppura- 
tion is quite exceptional. Although the separate tumors are much 
smaller than in the first group, the glandular mass is often a large one. 
because of the number of glands involved. 

It is seldom in either group of cases that the process is limited to a 
single node or even to two or three nodes. Very often an entire chain is 
involved. 

Tuberculous infection of the lymph nodes may terminate in resolu- 
tion, encapsulation, calcification, or suppuration. The inflammation may 
subside before caseation has taken place and the inflammatory products 
undergo absorption. After caseation has occurred the masses may be- 
come encapsulated and contract to small fibrous nodules. Calcification 
of the glands in this location is rare. In other cases caseation is fol- 
lowed by breaking down, liquefaction, and an external abscess. The 
course which the local disease takes will depend upon the intensity of the 
infection and the general vigor and resistance of the child. There is 
seen in most cases a tendency of the inflammation to subside spon- 
taneously about the time of puberty. Cure has sometimes followed an 
attack of intercurrent disease, such as erysipelas of the face, and even 
scarlet fever. 

Symptoms. — In the early part of the disease there are no symptoms 
but the glandular swelling, and this usually begins gradually. In many 
cases both sides are involved, but as the disease progresses the advanced 
changes are usually confined to one side. In other cases the first swell- 
ing noticed is an acute one, but, unlike other acute enlargements, it does 
not subside, but persists. The symptoms in most cases are characterized 
by remissions and exacerbations; the glands increase for a time and then 
remain stationary or even diminish, to take a new start from the stimu- 
lus of some fresh infection of the mucous membrane with which the 
glands are associated, such as an attack of measles or influenza, or sim- 
ply from a deterioration in the patient's general health. During exacer- 
bation the glands may be painful and tender and show the usual Bigns 
of local inflammation. 

The whole course of the disease varies from several months to as 
many years. As a rule the younger the patient the mote rapid its prog- 
ress. Treves gives three and n half years as the average duration when 



870 DISEASES OF THE LYMPH NODES 

suppuration occurs, but in infancy the glands sometimes break down in 
two or triree months. The glands first affected are usually those situ- 
ated near the bifurcation of the common carotid artery. Such tumors 
usually make their appearance just in front of the sternomastoid muscle 
— sometimes behind it — and at the level of the upper border of the 
larynx or the hyoid bone. In the more rapid cases the tumors usu- 
ally attain a considerable size in three or four months, sometimes in 
half that time. The usual size reached is from that of an almond to an 
English walnut. At first the tumors are movable and preserve their 
distinct outline; later they become adherent, first to the deeper tissues 
and to each other, finally to the skin, and there is formed an irregular 
nodular mass in which it is sometimes difficult to make out the individ- 
ual glands. As the process approaches the surface there are small spots 
of softening ; then there is distinct fluctuation ; the skin becomes discol- 
ored and finally gives way, and there is a discharge of thick, curdy pus, 
which may continue for an indefinite time, until the whole of the broken- 
down gland has been thrown off. This course is repeated with each suc- 
cessive gland which breaks down. In cases progressing more slowly the 
glands become adherent chiefly to one another, and suppuration is less 
frequent. 

In what proportion of tuberculous lymph nodes suppuration occurs, 
it is difficult to say. Like other tuberculous lesions in the body, this one 
is much more frequent than was once supposed; formerly, if glands did 
not break down in a few years, they were usually regarded as non-tuber- 
culous. We now know that a large number of tuberculous glands do not 
break down for many years and some never do. Two forms of suppura- 
tion occur in connection with tuberculous glands — one an abscess of the 
gland proper, the other outside of and usually over it. In a typical case 
of the first variety, the gland is distinctly outlined and often superficial, 
there is very little inflammation, the spot of softening and fluctuation is 
small, and the pus discharged is always curdy. In the second variety the 
abscess is preceded by a more diffuse swelling, and the outline of the 
gland may not be made out; the signs of inflammation are more marked, 
the area of fluctuation is larger, and the pus is more like that of any 
ordinary abscess. Often the two varieties are combined; as when a 
gland beneath the deep fascia breaks down and there is formed directly 
over it an abscess in the cellular tissue, which communicates through a 
narrow opening with the gland beneath. In such cases the sinus con- 
tinues open for a very long time, until the whole of the gland has been 
discharged. If healing occurs before this, the cicatrix soon breaks down. 

When abscesses are allowed to open spontaneously, large, irregular, 
and usually very intractable ulcers form. The skin is undermined for 
a considerable distance, and it has an unhealthy appearance. Such ulcers 



TUBERCULOUS ADENITIS 



871 



sometimes continue for many months in spite of all treatment, particu- 
larly if the patient's general health is poor. The scars left after them 
are large and unsightly, and sometimes positively deforming (Fig. 133). 
Their appearance is quite characteristic. They often have many tabs of 
skin attached to them; they may form prominent ridges which undergo 
contraction like those after burns; they are of a purplish-red color, and 
adherent to the deeper tissues. They are often sensitive and painful. 
As time passes they 
atrophy and become less 
conspicuous, though they 
remain throughout life. 

The general health of 
children with tubercu- 
lous glands of the neck 
is usually but little af- 
fected. Although the 
local process is often ex- 
tensive the absence of 
general symptoms is 
striking, and the secon- 
dary development of gen- 
eralized tuberculosis is 
infrequent. Both these 
facts indicate that bovine 
infection in the human 
subject is relatively 
mild. At any time in 
the course of the disease 
an examination of the 
throat often shows en- 
larged tonsils, but even 
when they are not gross- 
ly altered, serial section proves them to be tuberculous in a large propor- 
tion of the cases. 

Prognosis. — Tuberculosis of the external lymph nodes is seldom if 
ever the direct cause of death; although the course is often very pro- 
tracted, ultimate recovery can usually be predicted. Treves states that 
the percentage of those who die from general tuberculosis is so small 
that this danger is not to be considered an argument for operation. 
Poore reports that of 58 cases treated by operation, only 2 were known 
to have died from tuberculosis. Dowd lias collected reports of 309 cases, 
chiefly hospital patients, treated by removal more or less complete, whose 
course was followed for several years after operation. Of these, 202, or 




Fig. 133. — Cicatrices Following a Neglected Case 
of Tuberculous Adenitis, in a Girl Seven 
Years Old. There is also a tuberculous patch 
upon the skin of the cheek in a not infrequent 
location. 



872 DISEASES OF THE LYMPH NODES 

65 A per cent, were apparently cured; 57, or 18.4 per cent, were living, 
though suffering from either local or general tuberculosis; 50, or 16.2 
per cent, died of tuberculosis. These statistics hardly support the hope- 
ful views of the writers first quoted, but they are. we believe, more in 
accord with general experience in the class which makes up hospital 
patients. In private practice the results are much be iter. 

Diagnosis. — The diagnostic features of tuberculous glands are the 
age of the patient — usually from two to ten years — the site of the pri- 
mary swelling, the indolent course, the trifling original cause, and the 
disposition to slow caseation, softening, and abscess. The cutaneous tu- 
berculin reaction is of great assistance in diagnosis; in a young child a 
positive reaction is significant, while at any age a negative reaction is 
usually conclusive. The cases of simple inflammation are usually in chil- 
dren under three years, their progress is much more rapid. If they do not 
break down they generally disappear in the course of four or five months. 
They usually suppurate, if at all, during the first month. Chronic glan- 
dular enlargements which persist are usually tuberculous, no matter 
how good the surroundings or the general health. Syphilitic disease of 
the cervical glands is relatively rare in children. It is recognized by 
the Wassermann test, by the evidence of syphilis elsewhere, and by the 
effect of treatment. In Hodgkin's disease, glandular groups in other 
parts of the body are involved simultaneously or in rapid succession. 
There are no signs of inflammation or caseation; and the swellings are 
usually accompanied by very marked and definite general symptoms and 
blood changes. Malignant growths are very rare ; they increase rapidly, 
often attaining a great size in a few months. 

Treatment. — As the tonsils are so frequently the seat of infection it 
is important to examine these most carefully in every case. Unless it is 
entirely clear that they are free from disease they should be removed. 
Eemoval of tuberculous tonsils is sufficient in many cases to bring about 
cessation of the process in the cervical glands. Many begin to diminish 
in size shortly after tonsillectomy. If it is done early in the disease 
suppuration of the glands is much less likely to occur. Adenoid growths 
of the rhinopharynx and carious teeth should also receive attention. 

A child from the city should be sent into the country whenever this 
is possible. The seaside has a great reputation in such cases and no 
doubt the majority do very well there, but some are benefited even more 
by a dry mountain climate. Climatic treatment is to be recommended 
particularly for those children who have pulmonary lesions and there- 
fore infection with the human type of organism. Those with only tonsil- 
lar and glandular tuberculosis do well with the removal of the focus. 
This should not be neglected in any case. 

Drugs are of little benefit. Cod-liver oil, arsenic and iron are useful 



TUBERCULOUS ADENITIS 873 

only as general tonics. Local applications are of little value. The parts 
should not be rubbed or handled. 

Brilliant results have been reported by Kollier of Switzerland of 
treatment by heliotherapy, or the exposure of the diseased parts directly 
to the sun's rays. This is especially to be recommended for old cases 
with extensive lesions, when complete removal is impossible or when 
operation wounds do not heal. 

Operative Measures. — These are indicated, if after the removal of the 
probable foci and a trial for a few months of climatic and general meas- 
ures, the glands do not diminish but rather increase in size and number, 
or if there are signs of softening. The advantages of operation are that 
it leaves a clean scar which when the incision is properly made is almost 
imperceptible; that it shortens the disease; that if thoroughly done and 
the deep as well as the superficial glands are removed, it is a radical 
measure. The best results follow when operation is done reasonably 
early before the skin is involved or the glands have softened or have 
formed extensive adhesions to the great vessels and neighboring struc- 
tures; also when a chain of glands is involved and when the inflamma- 
tory process is slow or indolent. A thorough operation by a good sur- 
geon in the great majority of cases will result in a permanent cure. 
However, the operation is not contra-indicated in cases which have gone 
on to a later stage, although the results may not be quite so satisfactory. 

If more radical measures are for any reason impossible, glandular 
abscesses should be opened as soon as pus forms, to prevent the extensive 
undermining of the skin, which is likely to occur. The. opening should 
be a small one, and all squeezing of the gland or surrounding tissues 
avoided. 

As an alternative to operative measures, or when these are refused, 
exposure to the X-ray may be tried and in a certain proportion of cases 
it is curative. The best results are seen in the early cases. The first 
exposures should be short, and they should be repeated not oftener than 
once a week. 

Tuberculin Treatment. — This has been employed extensively with 
a number of different preparations obtained from cultures of tubercle 
bacilli. 1 It is the general consensus of opinion that this met lied of treat- 
ment is of benefit, and that it diminishes the tendency to softening and 
promotes resolution. Our own belief is that it should not and can qoI 
lake the place of operative measures. 

*The preparations of tuberculin most widely used are B.F. (bouillon lilnvi 
of Denys; O.T. (original tuberculin).; T.R. (tuberculin residue), ami B.E. 

(bacillary emulsion). 

The doses are calculated in milligrams, it being considered thai one cubic 

centimeter of the fluid weighs one gram, which is nearly if no1 quite the case. 



874 DISEASES OF THE LYMPH NODES 

The purpose is to give enough tuberculin to affect the local process, 
but never enough to produce a general systemic reaction — fever, malaise, 
swelling of the glands, etc. It is necessary to begin with a very small 
dose and to increase this gradually. If there is any elevation of tempera- 
ture following an injection, the amount should be diminished to a quarter 
or less of the dose given and a return made to the amount causing the 
reaction only after several weeks. The best indication that one has 
reached the point where an increase in dosage is to be made with especial 
care, is the reaction produced at the site of injection. When this is made 
subcutaneously there may be around the point of injection a slight swell- 
ing, induration and tenderness for some days. Injections should be re- 
peated every four or five days. An initial dose of .00002 mgm. is proper 
for an average child of two or three years. The dose may be doubled at 
each injection until .05 mgm. is injected. After this it is safer to re- 
peat the same dose two or three times before increasing further and to 
give this dose at weekly intervals. It is not advisable to increase beyond 
.1 gm. as the maximum dose. The duration of treatment will depend 
upon the effect upon the glands. It is usually several months. Even 
when the results have been favorable it is considered advisable by many 
to repeat the course of treatment after an interval of some months. 

HODGKIN'S DISEASE 

(Pseudo-Leukemia) 

Hodgkin's disease at the present time is to be considered a distinct 
clinical and pathological entity. For many years there was no general 
agreement regarding its determining characteristics and in the older 
literature many cases were included which were undoubtedly not Hodg- 
kin's disease. The condition is relatively rare. In infancy it is almost 
unknown, but after the age of three years it is found with increasing 
frequency throughout childhood. It is much more common in males. 
The essential cause of Hodgkin's disease is unknown. Numerous organ- 
isms have been described in connection with it, especially modified forms 
of the tubercle bacillus and more recently diphtheroid bacilli. It is 
doubtful if the disease results from infection with any of them. 

Pathology. — The chief lesion is in the lymph nodes, which become 
greatly enlarged and in addition new ones develop during the course of 
the disease. Those first affected are usually in the neck, but any of the 
external or internal groups of lymph nodes may be affected and in 
severe cases the disease may involve almost every chain of glands in the 
body. Of the internal glands those of the mediastinum and retro- 
peritoneal region are usually most affected. Large masses are formed 



HODGKIN'S DISEASE 875 

by the growth and multiplication of the lymph nodes, but even in the 
largest masses the individual nodes are discrete and are held together 
only by loose connective tissue. The spleen is usually, the liver less fre- 
quently, involved and somewhat enlarged by the formation of lymphoma- 
tous masses, which may also infiltrate almost any tissue of the body. 
Microscopically, the early changes in the glands consist in an increase 
in the lymphoid tissue. Later there is proliferation of the endothelial 
cells, the formation of giant cells and an overgrowth of connective tissue. 
The eosinophile cells are frequently present in the tissues in great num- 
bers. The lymphomatous masses in the spleen and other organs have 
the same structure microscopically as the diseased nodes. 

Symptoms. — The first evidence of disease is usually the swelling of 
one or more cervical glands. Thereafter there is a progressive involve- 
ment of other glands, though the rapidity with which this occurs may 
vary greatly. At the beginning the general health remains unaffected 
and this usually continues until the glandular enlargement is wide- 
spread. Then a more or less persistent fever may develop or anemia 
supervene or pressure symptoms make themselves evident. 

The fever may be irregular, with wide excursions and periods of re- 
mission, or, what is more common, it may be only of a degree or two but 
persistent. The blood shows the characteristics of a secondary anemia, 
which increases in severity. The leucocytes may be slightly diminished 
or increased, but in the late stages there is usually a polymorphonuclear 
leucocytosis (20,000-30,000 or more). There are two constant features, 
an increase in the blood platelets and an increase in the transitional leu- 
cocytes. Eosinophiles, while usually somewhat diminished, may be 
present in great numbers. 

The glandular masses can be felt to be made up of discrete glands. 
These are elastic, sometimes distinctly soft, at others, firm. They are 
more or less movable and not adherent to the deeper structures nor to 
the skin over them. At any time symptoms may appear as the result 
of the mechanical pressure of the glands. This may be on the vessels 
of the neck or extremities, producing edema; upon the esophagus, pro- 
ducing dysphagia; or upon the trachea or bronchi, producing dyspnea. 
Intra-abdominal pressure may cause jaundice or chylous ascites. In 
most cases enlargement of the spleen can be made out. In some in- 
stances it is extreme. 

The duration of the disease is usually less than three years, some- 
times only a few weeks. There may be periods in which the progress 
seems arrested, but they are usually short.- Death results from asthenia, 
or from pressure usually upon the respiratory tract, producing slow suffo- 
cation with most distressing Bymptoms. The prognosis is had. We 
know of no children with Hodgkin's disease thai have recovered, 



876 DISEASES OF THE DUCTLESS GLAXDS 

Diagnosis. — The diagnosis of Hodgkin's disease may be difficult at 
the beginning, when only a few cervical glands are enlarged. It may 
be confounded with glandular tuberculosis, with lymphosarcoma and 
with leukemia. From tuberculosis it is to be differentiated by the wide 
distribution of the progressively enlarging glands; by their failure to 
coalesce, to exhibit inflammatory reaction or to suppurate; by the fre- 
quent absence of the von Pirquet reaction and by the more malignant 
course and pressure symptoms. Lymphosarcoma is more rapid in its 
course, does not usually cause fever, the glands do not remain so discrete 
as in Hodgkin's disease and the spleen is seldom involved. Leukemia is 
distinguished by less lymphatic enlargement, by greater rapidity of prog- 
ress, especially in the lymphatic form, and especially by the character of 
the blood findings. In doubtful cases the excision and examination of 
a gland will almost always give reliable information as to the presence 
or absence of Hodgkin's disease. 

Treatment. — This is very unsatisfactory, but some remedies appar- 
ently are of temporary benefit. Arsenic in full doses appears to benefit 
some patients. The use of the X-ray has produced striking but not 
permanent improvement in the external glands. Eecently vaccines pre- 
pared from the diphtheroid bacilli cultivated from the glands have been 
employed. It is too early to judge of the influence of this method of 
treatment. Tracheotomy occasionally is employed to relieve dyspnea, 
but is seldom indicated because the obstruction to respiration is usually 
situated very low in the neck or in the thorax. 



CHAPTEE III 



DISEASES OF THE DUCTLESS GLANDS 
THE SPLEEN 

Weight. — From 110 observations made at the Xew York Infant 
Asylum the following were the weights recorded at the different ages : 



Age. 


Ounces. 


Grams. 


Birth 


H 

% 
1^ 


7.7 


Three months 


15.5 


Twelve months 


23.2 


Two years 


38.5 


Three years 


46.4 







DISEASES OF THE SPLEEN 877 

Position and Methods of Examination. — The normal position of the 
spleen is close against the diaphragm, its external surface being opposite 
the ninth, tenth, and eleventh ribs. Its anterior border comes as far 
forward as the middle axillary line, its posterior border being usually 
near the vertebral column. In infancy it is practically impossible to 
outline the spleen by percussion unless it is enlarged. During full in- 
spiration the spleen is often depressed enough to be felt at the free border 
of the ribs, but at other times it can not be felt unless it is enlarged or 
pushed downward by some pathological condition in the chest. Nor- 
mally, the long axis of the spleen is nearly parallel with the ribs, but 
when the organ is much enlarged, its axis corresponds nearly with a line 
drawn from the axillary line at the border of the ribs to the middle of 
Pouparfs ligament. 

The thin abdominal walls of young children render palpation of the 
spleen much easier than in adults ; and this is a much more satisfactory 
method of examination than is percussion. For satisfactory palpation 
it is necessary that the abdominal walls should not be tense. The child 
should lie upon his back with the thighs flexed and the skin, of course, 
bared. The physician, always having taken the trouble to warm his 
hands, should stand upon the left side of the patient and make pressure 
with the tips of the ringers, which are semi-flexed. The pressure should 
be at first light, and gradually increased, the fingers being then held 
stationary during two or three respiratory movements. Under ordinary 
conditions the spleen can easily be felt when it is sufficiently enlarged 
to be of any diagnostic importance. 

When moderately enlarged, the lower border of the spleen is an inch 
or so below the free border of the ribs; when greatly enlarged, it forms 
a tumor which may nearly fill the left half of the abdomen. A tumor 
in the left hypochondriac region is recognized to be the spleen, by the 
fact that it is freely movable laterally and at its lower border or ex- 
tremity, while it is attached above; also its inner border can usually 
be felt to be thin and sharp, and marked about its middle by quite a 
deep notch. 

ENLARGEMENT OF THE SPLEEN 

In Acute Disease. — The spleen is mosl frequently and mosi con- 
stantly enlarged in malarial and typhoid fevers, but it is occasionally so 
in all the acute infections diseases. 

In most of these cases, the enlargement is chiefly from congestion, but 
there may be acute hyperplasia and an increase in size of the Malpighian 
bodies. It may contain small hemorrhages, and in extremely rare cases 
the spleen may rupture. It is generally dark-colored, soft, and sonic- 



878 DISEASES OF THE DUCTLESS GLANDS 

what friable. In the cases which recover, the splenic swelling subsides 
with the original disease. 

In Chronic Disease. — Like the lymph nodes, the spleen is much more 
often enlarged in children, particularly young children, than in adults. 
Enlargement is seen at times in almost all the chronic diseases of early 
life; but it occurs most frequently in rickets, syphilis, malaria, tuber- 
culosis, the blood diseases, and in amyloid degeneration. Besides, it may 
be the seat of a primary growth, either benign or malignant. 

Rickets. — The splenic enlargement which accompanies rickets is gen- 
erally seen during the first year ; at this period it is very frequent. The 
swelling is usually moderate, but occasionally it is so great that the 
lower border is three or four inches below the ribs. 

Syphilis. — Enlargement of the spleen is one of the most constant 
lesions of hereditary syphilis. It is present with great uniformity in 
children born with syphilitic lesions, and very frequently during the 
active period of the disease in early infancy. It is seen at a later period 
during infancy or childhood, associated with other late symptoms. 

Malaria. — The swelling in cases of chronic malaria may be very great. 
The liver is not so often enlarged as in syphilis. 

Tuberculosis. — It is rare to find anything more than a moderate 
swelling of the spleen in pulmonary tuberculosis. In general miliary 
tuberculosis, enlargement of the spleen is an almost constant finding. 
The enlargement is usually progressive, due to an increase in the number 
and size of the tuberculous deposits which are regularly present. 

Diseases of the Blood. — Marked enlargement of the spleen is found in 
many cases of secondary anemia. The spleen is constantly swollen, and 
usually greatly so, in the pseudoleukemic anemia of infants, in leukemia, 
and in Hodgkin's disease. In the last two diseases the liver is also en- 
larged, but to a much less degree than the spleen ; in the others it is but 
slightly changed. 

Amyloid Degeneration. — The spleen is constantly involved in amy- 
loid disease, and the enlargement of this organ, as well as that of the 
liver, may be very great. 

Cardiac Disease. — In all forms of cardiac disease, and in other con- 
ditions in which there is obstruction to the systemic venous circulation, 
the spleen is enlarged. It is seen in congenital as well as in acquired 
cases. The liver is usually enlarged, and there may also be edema of 
the feet or general anasarca. 

New-growths, Tumors, etc. — It is seldom in early life that the spleen 
is the seat of new-growths; these are usually varieties of sarcoma, but 
carcinoma has also been reported. 

Banti's Disease— Splenic Anemia. — These are rather unsatisfactory 
terms which are used to designate a clinical condition which is, at 



DISEASES OF THE SPLEEN 879 

times, capable of sharp differentiation, but which pathologically has no 
especially distinguishing features. In the late stages, the lesions are 
essentially those of periportal cirrhosis of the liver. The spleen is 
greatly enlarged and shows a marked increase in the fibrous tissue both 
of the capsule and reticulum. In the early stages the Malpighian 
bodies may be enlarged. In the late stages they are small and in- 
frequent. 

The onset is late in childhood, usually not before the tenth year, and 
the progress is slow. Attention is generally first attracted to the anemia 
and the symptoms that accompany it, such as dyspnea on exertion and 
cardiac palpitation. The anemia has the characteristics of a secondary 
anemia. There is usually a moderate, relative increase of the lympho- 
cytes. There may be from time to time slight rises of temperature and 
occasionally epistaxis. Physical examination shows in such instances a 
moderately enlarged and firm spleen. The splenic enlargement is very 
slow but progressive. It is never extreme. After a time a slight in- 
crease in size of the liver occurs. The progress of the disease is very 
gradual. A fair degree of health may be maintained for ten or twelve 
years. Then there are superadded the evidences of hepatic cirrhosis. 
The liver diminishes in size until it can no longer be felt. There may 
be icterus and urobilinuria and eventually ascites with dilatation of the 
abdominal veins, hematemesis and submucous hemorrhages. Death 
usually occurs from some intercurrent disease before the development 
of the evidences of hepatic insufficiency and obstruction. 

The justification for considering Banti's disease a clinical entity, 
distinct from cirrhosis of the liver, with which the pathological findings 
are nearly identical, rests upon the duration of the symptoms, the dis- 
proportionately large spleen and the frequent absence of ascites and 
icterus. The course of true cirrhosis of the liver in the young is often 
rapid; the duration is usually a year or less. The enlargement of the 
spleen is generally slight, while ascites often develops early and is very 
obstinate. Syphilis of the liver and spleen may be difficult to differen- 
tiate from Banti's disease by physical examination alone, and several 
cases diagnosed as Banti's disease have been shown at autopsy to be syphi- 
litic in origin. The evidence afforded by the Wassermann reaction and 
by careful examination for syphilis of other parts of the body should be 
sought. Hemolytic jaundice may be excluded if there is no increased 
fragility of the red cells. In Gaucher's disease the progress is also slow 
and a reasonable degree of health may be maintained for many years. 
There is often, however, a history of several cases in the same In mil y ; 
there may be a brownish discoloration of the skin ; after some years the 
liver is also enlarged and the spleen eventually reaches proportions found 
in no other disease. 



880 DISEASES OF THE DUCTLESS GLANDS 

It has been maintained by Banti that the spleen is the primary factor 
in the disease and that the liver is secondarily affected. There is little 
to substantiate this view, except that in the early stages of the disease 
striking benefit results from splenectomy. Sufficient time has not yet 
elapsed, nor have sufficient cases been recorded, to prove how permanent 
the benefit will be. It is clear, however, that splenectomy is indicated 
in the stages of the disease before serious involvement of the liver. 
When ascites has developed palliative treatment alone should be em- 
ployed. 

Hemolytic Jaundice — Chronic Family Jaundice. — This disease is 
usually hereditary, but it occasionally exists in several brothers and sis- 
ters, the parents being unaffected. Similar cases may be seen without a 
family association. There are records of many families in which jaun- 
dice has existed through three or four generations. It is transmitted 
alike through the male and female descendants, and not all of the chil- 
dren in a family are affected. The descendants of unaffected members 
escape. The jaundice may be noticed shortly after birth, or it may de- 
velop at any time during childhood, sometimes not until later. This is 
the most striking feature of the disease. The discoloration may be very 
slight and noticeable only in the sclerotics, or the skin may be icteric. 
The color is never very intense. It varies somewhat in degree and is in- 
creased after intercurrent gastro-intestinal attacks, which are rather fre- 
quent. When once developed, the icterus never entirely disappears. 

This jaundice is not obstructive; the stools are usually darker than 
normal and the urine contains urobilin in excess, but no bile. There is 
an increased production of biliary pigment. The liver is normal or 
slightly enlarged. The spleen is regularly, and often excessively, -en- 
larged, and even in youth there may be attacks of biliary colic and of 
perisplenitis. Anemia of a moderate grade is the rule. Both the red 
cells and hemoglobin are reduced, and a few nucleated red cells may be 
found. Eeticulated red cells may be demonstrated by means of vital 
staining. As many as 20 per cent of the total red cells may be reticu- 
lated as opposed to the normal of 1 per cent or less. Very characteristic 
of the disease is the increased fragility of the red cells to hemolytic 
agents, especially to hypotonic salt solutions. Normal red cells are not 
hemolyzed by solutions of sodium chlorid of a concentration of 0.5 per 
cent or more. With salt solutions of 0.45 per cent hemolysis begins and 
is complete with those of 0.35 per cent. With hemolytic jaundice hemol- 
ysis usually begins with solutions of a concentration between 0.7 and 0.6 
per cent and is complete with those between 0.55 and 0.45 per cent. 

The growth and development of children go on uninfluenced by the 
condition, and many affected persons have lived to an advanced age. 
There are no characteristic post-mortem findings. Various drugs, among 



DISEASES OF THE SPLEEN 881 

them iron and arsenic, have been employed in treatment. The only 
effective method is surgical. Splenectomy has been employed with 
marked improvement in several instances. In some cases, symptomatic 
cure has been reported. Splenectomy should be done if there is much 
interference with the patient's general health. 

Gaucher's Disease. — This is a rare disease, which frequently attacks 
two or more members of a family, but is not hereditary. It usually be- 
gins before the age of ten years and cases have been reported in the first 
year of life. The most striking feature is an enlargement of the spleen, 
which is slowly progressive and may eventually nearly fill the abdomen. 
It is firm, smooth and not tender. While never reaching the proportions 
of the spleen, the liver may be considerably increased in size. It is also 
smooth. A secondary anemia with leucopenia is constantly present but 
is not severe. Associated with this is a peculiar brown discoloration of 
the skin, particularly of the face. In some instances, there is a yellowish 
wedge-shaped thickening of the conjunctiva on either side of the cornea. 
The superficial lymph glands may be palpable, but are not materially 
increased in size. The general health may be fair for many years. The 
splenic and hepatic enlargements may cause abdominal discomfort and 
even pain, but it is rare for jaundice or ascites to develop. Eventually 
hemorrhages may occur from slight traumatism or spontaneously from 
the mucous membranes. 

The disease may last many years. Death usually results from some 
intercurrent disease. While the origin of the disease is obscure, the 
pathological findings are entirely distinctive. Microscopically it is seen 
that the enlargement of the liver and spleen is due to the accumulation 
of characteristic cells which widely invade these organs. The cells are 
very large, with small excentrically situated nuclei and with slightly 
granular cytoplasm. These cells are found not only in the spleen but 
also in the bone marrow and lymph glands. The accumulation in the 
lymph glands is not sufficient to cause marked enlargement, but is im- 
portant as showing that the disease is a systemic one, and not primarily 
one confined to the "spleen. The presence of the distinctive cells in the 
glands may be of assistance in diagnosis, as in a case reported by Knox, 
in which the suspected diagnosis was confirmed by the microscopical 
examination of an excised lymph node. 

Medical treatment does not influence the course of the disease. On 
a priori grounds it does not seem likely thai splenectomy will produce 
permanent cure in a disease whose lesions are so widely distributed in 
other organs. A number of cases, however, have been operated upon and 
some have shown a distinct improvement. The time that has elapsed in 
the majority is, however, too short to enable a definite conclusion as to 
the final result to be reached. 



882 DISEASES OF THE DUCTLESS GLANDS 

DISEASES OF THE THYROID 
SPORADIC CRETINISM 

(Athyreosis; Myxedematous Idiocy) 

Since the early descriptions of this disease by Fagge, in 1871 and 
1874, numerous cases have been published in England, on the continent 
of Europe, in America, and in fact, all over the world, showing that 
sporadic cretinism is not confined to any country. The condition is a 
relatively rare one, but in a large dispensary and hospital service one or 
more examples of it are seen every year. 

Etiology. — It is now well established that this condition depends 
upon the absence of the internal secretion of the thyroid gland. In 
almost all the autopsies in cases of sporadic cretinism that have been 
reported there has been an entire absence of the thyroid gland. Not even 
a trace of it has been found. In one or two instances cysts have been 
met with in the region of the lateral rudiments of the thyroid gland, or 
at the root of the tongue in the region of the median rudiment. These 
cysts may contain a few cells resembling thyroid tissue, but nothing 
that is apparently capable of functionating. There are no recorded ob- 
servations upon cases of sporadic cretinism that would indicate that an 
already developed thyroid gland had been affected by injury or disease. 
The absence is due to a congenital lack of development such as produces 
anencephaly or the absence of other parenchymatous organs. As a rule 
only one case occurs in a family, the other members of which present 
nothing abnormal in mental or physical development. 

There are associated no constant changes in the other ductless glands. 
In the few cases in which the parathyroids have been searched for at 
autopsy they have been found. Alterations in the pituitary gland have 
been quite frequently reported. It has been found hypertrophic and 
occasionally cystic, but this is not constant. 

Symptoms. — The symptoms of cretinism in most cases make their 
appearance during the second half of the first year, but are sometimes 
so slight as not to be noticed until children are two or three years old. 
Very rarely the condition is recognized as early as the third or fourth 
month. The delay in the development of the symptoms is to be ascribed 
to the protection afforded the infant by the thyroid secretion of the 
mother during intrauterine life. This view is substantiated by the rare 
but undoubted instances where women with either goiter or hyperthyroid- 
ism have borne infants with cretinism which was clinically recognizable 
at birth. Failure to grow and to develop mentally are usually the first 



SPORADIC CRETINISM 



883 



things to attract attention. The peculiarity of the facial expression is 
soon noticed. The general appearance of the cretin is striking, and so 
characteristic that when once seen the disease can hardly fail to be recog- 
nized (Fig. 134). The body is greatly dwarfed, and children of fif- 
teen years are often only two and a half or three feet in height. All 
the extremities, the ringers and the toes, are short and thick. With 
cretins of ten years of age, or even more, the relative infantile proportions 





Fig. 134. — A Typical Cretin; 
Two and a Half Years 
Old. A patient in the Babies' 
Hospital. 



Fig. 135. — Same Patient at Six and One-third 
Years. 



of the body are maintained. There is almost complete lack of growth at 
the epiphyseal junctions and there is great delay in the development of 
the centers of ossification. X-ray studies show that the nuclei of the 
tarsal and carpal bones may be absent until the tenth year and that the 
epiphyses of the long bones may not be ossified until the twentieth or 
thirtieth year. The subcutaneous tissue seems very thick and boggy, but 
does not pit upon pressure like ordinary edema. The facies is extremely 
characteristic. The head seems large for the body; the fontanel is often 
open until the eighth or tenth year, and it may not be closed even in 



884 DISEASES OF THE DUCTLESS GLANDS 

adults, but the cranial bones are often very thick; the forehead is low 
and the base of the nose is broad, so that the eyes are wide apart ; the lips 
are thick, the mouth half open, the tongue usually protrudes slightly; 
the cheeks are baggy, the eyelids thick, the hair coarse, straight, and 
generally light-colored. The teeth appear very late and are apt to decay 
early. The second dentition may not begin until adult life. 

Fatty tumors are quite constant in older children, although they 
are often wanting in infantile cases. They are seen in the supraclavicu- 
lar region, just behind the sternomastoid muscle, sometimes in the ax- 
illa, or between the scapulae, and sometimes in other parts of the body, 
In distribution they are apt to be symmetrical, and are usually about 
half the size of a hen's egg. The neck is short and thick. No thyroid 
gland can be made out by palpation, but a small cyst may sometimes be 
felt at the root of the tongue. The chest is not deformed. The abdomen 
is large and pendulous. An umbilical hernia is almost always present. 
The skin is dry, perspiration scanty, and eczema is common. The voice 
is hoarse and rough. Frequently patients may not walk until they are 
five or six years old, and then they waddle in a clumsy way. All the 
movements of the body are slow and lethargic, and everything indicates 
mental and physical torpor. The rectal temperature is usually subnor- 
mal. We had once an opportunity to observe an attack of acute broncho- 
pneumonia in one of these cretins two years old. The symptoms and 
physical signs were typical, but during the greater part of the disease the 
rectal temperature fluctuated between 95° and 98.5° F. Only once was a 
temperature above 99° F. recorded. On account of their low tempera- 
ture and torpid condition these patients are very sensitive to cold. They 
live upon a low plane of metabolism and the energy exchange is small. 
The mental condition is always greatly impaired. Some are even imbe- 
cile. Cretins are dull, placid, and good-natured, rarely troublesome or 
excitable; and when fifteen or eighteen years old they appear like chil- 
dren of three or four years. Speech may be impossible. The ability to 
say a few words is acquired late, and in some cases not at all. Almost 
invariably cretins suffer from constipation. At the age of puberty there 
is an absence of development of the sexual organs. 

Diagnosis. — The diagnosis of the fully developed condition is very 
easy. The facial expression, the protruding tongue, the pendulous abdo- 
men with umbilical hernia, the fatty tumors, torpor and low tempera- 
ture are sufficient to characterize cretinism. The mistake is sometimes 
made of confusing Mongolian idiocy with cretinism. The former may be 
recognized by the peculiar formation of the eyes, the normal bone forma- 
tion and growth and by the presence of the symptoms at birth. The 
therapeutic test with thyroid extract is conclusive. 

Prognosis and Treatment. — There is no tendency to spontaneous 



SPORADIC CRETINISM 885 

improvement. If untreated, cretins may live to an advanced age, but 
remain dwarfs, seldom attaining a height of more than three or three 
and a half feet. Their mental condition remains unimproved. Treat- 
ment with preparations of the thyroid gland brings about an extraordi- 
nary change. Transplantation of the gland has been employed as well 
as subcutaneous injection of extracts and the ingestion of fresh glands 
and various substances obtained from the gland. All these methods are 




,^r> 



Fig. 136.— Dr. J. P. West's Case of 
Cretinism, Seventeen Months 
old, Before Treatment. 




Fig. 137. — After Six Months' 
Treatment with Thyroid 
Extract. 



effective, but the preparation most employed is the dried, powdered 
gland, usually called thyroid extract, given by mouth. It is nearly a 
specific remedy for this disease. The improvement after its use is truly 
remarkable (Figs. 136 and 137). After a few weeks' treatment the en- 
tire appearance of the child is changed. The idiotic expression of the 
face Is lost; tbe thickening of the skin and subcutaneous tissues disap- 
pears; there is a marked increase in heighl and in the circumference of 
the head; muscular power is rapidly developed, so that many soon be- 
come able to walk; and progress is seen in dentition, and in some older 



886 DISEASES OF THE DUCTLESS GLANDS 

girls in the establishment of menstruation. Intellectual progress is 
much slower than physical changes; however, nearly all the children 
become much brighter and more intelligent and learn to speak. 

If treatment is begun early, physical development may be apparently 
normal, but normal mental development we have not seen, even in cases 
in which treatment was begun during the first year. We have under 
observation several cretins who have been treated from ten to fifteen years. 
Many of these children seem quite intelligent and are able to attend 
school, but without exception they are much below other children of 
their ages in mental and usually in physical development. As the thy- 
roid gland is absent in these patients it is necessary for them to con- 
tinue taking the thyroid extract as long as they live. If it is omitted 
relapses occur in a few weeks, even in cases well advanced toward re- 
covery. 

Most of the thyroid extracts on the market are prepared from the 
glands of the sheep. A reliable extract should be given if results are 
to be expected. The thyroid extract of Burroughs and Wellcome we 
have found to be more satisfactory than many of those on the market. 
Of this half a grain may be given once or twice a day at first; after 
the child becomes somewhat accustomed to it the daily dose may be 
gradually increased to five or six grains. Some disturbances are often 
seen at the beginning of the treatment — perspiration, marked irritability, 
and sometimes a rise in temperature — but these soon pass off. For old 
cases at least five grains daily should be given for an indefinite period. 



HYPOTHYROIDISM 

(Infantile Myxedema) 

Cases of undoubted thyroid deficiency are met with that differ from 
sporadic cretinism in the time of their development and in the severity 
of the symptoms. Among them should be classed those cases closely 
resembling cretinism but not showing symptoms until the second or 
third year or even later and then only slightly marked symptoms. The 
deficiency of the thyroid under such circumstances occurs in extra- 
uterine life or is incomplete. There are no pathological studies to 
show the condition of the gland and the etiological factors causing its 
degeneration are unknown. In a certain number of instances the condi- 
tion has followed some acute infectious disease. The symptoms are 
those that base been mentioned under sporadic cretinism, differing only 
in degree. It is usually the failure of mental or physical develop- 
ment that first attracts attention; the child is unable to learn, pays 



HYPOTHYROIDISM 



887 



no attention to commands, is not cleanly in his habits, or he is much 
smaller than his fellows. More rarely he is noticed to have lost the 
ability to do things which he had formerly acquired. The height of 
these children is much below the average but the degree of dwarfism 
depends upon the time of onset of the thyroid deficiency. Some are 
greatly stunted, others less so; but normal growth does not occur and 
increase in height is very slight or absent. X-ray pictures show, as 
a rule, the presence of sorfie carpal and tarsal centers of ossification 
which indicate that for a time at least the 
thyroid has been active. The facial expression 
varies from the characteristic facies of cretin- 
ism to one that is only slightly expressionless, 
stupid or stolid. The lips are apt to be some- 
what thickened, the tongue also, but by no 
means always protruded. The hair is often 
coarse and generally thick. The children are 
usually well nourished, often stout. The skin 
is dry and thickened and the subcutaneous tis- 
sue firm. Fat pads are exceptionally present. 
The abdomen is usually large and in the more 
pronounced cases there is a hernia in the umbil- 
ical region. In the less marked cases this is 
often lacking. The children readily complain 
of cold. Constipation is frequent but by no 
means the rule. Dentition is late and irregular 
and the second dentition delayed. The voice is 
usually deep and hoarse. 

These children are quiet and placid. Their 
intelligence varies according to the severity of 
the disease. Some are imbecile, some have quite 
a high degree of intelligence, so that, though 
several years behind their fellows, they are able 
to attend school. In the marked cases it is hardly possible to err in 
diagnosis. The mild cases can only be determined positively by the effect 
of thyroid extract upon the symptoms and especially upon growth. Tims. 
in one of our cases aged three and a half (Fig. L38) the height which 
had been stationary for some months increased Dearly four inches in six 
months as the result of thyroid medication. 

Treatment with thyroid brings about prompt improvement which 
will vary in extent according to the severity of the condition. Striking 
mental and physical improvement occurs. It is doubtful if complete 

intellectual development takes place. It is not to he expected that 
recovery of function in the diseased thyroid can occur. For this reason. 




Fig. 138. — Infantile Myx- 
edema. 



888 DISEASES OF THE DUCTLESS GLANDS 

thyroid extract should be given continuously in the doses advised in 
the previous chapter. Mental and physical deterioration occur if its 
administration is interrupted. 

GRAVES' DISEASE 
{Exophthalmic Goiter, Basedoiv's Disease) 

Typical Graves' disease in young children is rare. The determining 
cause of the perversion of the thyroid activity is unknown. Hereditary 
influences, especially goiter, Graves' disease and alcoholism are believed 
to play a part. Much more important is the effect of sex and age. 
Girls are affected three times as often as boys. As the age of puberty 
is approached the cases become much more frequent. Under five years 
of age Graves' disease is almost unknown. The youngest case that has 
come under our observation was in a girl of five and a half years. 
Between five and ten years a number of cases have been reported, but 
after ten years it is not very infrequent. 

The disease as it occurs in childhood differs chiefly in two respects 
from the type seen in adult life. The symptoms develop and disappear 
with much greater rapidity, perhaps even in the course of a few days, 
and it is generally believed the outlook with the child is much more 
favorable. 

Symptoms. — Attention is usually first called to the disease by rest- 
lessness and excitability or by the rapidity of the heart's action. En- 
largement of the thyroid may not be evident at first but is regularly 
present at some time during the disease. The gland is generally uni- 
formly enlarged, sometimes to a marked degree; it is firm, often hard, 
and can be felt to pulsate. With improvement in the symptoms there 
is a marked diminution in size, but a slight degree of permanent 
enlargement usually remains. 

Exophthalmus is present in about four-fifths of the cases. It may 
be extreme. The ocular signs of von Stelwag and von Graefe are both 
present in the majority of cases. The fine tremor so commonly present 
with adult patients is usually lacking. Involuntary movements, if 
present, are generally coarse incoordinate movements. The skin is 
often fine and moist. Perspiration is readily excited, and flushing is 
frequent. Pigmentation is unusual. The heart's action is usually rapid 
and its violence is often complained of. A slight amount of cardiac 
dilatation may frequently be determined by physical examination. Ner- 
vousness is pronounced and is in most cases an early symptom. The 
children are constantly in motion and can be kept quiet with difficulty. 
The first improvement is often noticed in a diminution of the restless- 



HYPERTHYROIDISM 880 

ness. The appetite is usually fair and the digestion good, but, as with 
adults, the increased metabolism which accompanies excessive thyroid 
activity causes loss of weight. Marked emaciation occasionally results. 

The diarrhea, so troublesome a symptom with the adult form of the 
disease, is seldom marked. In general it may be said that the disease is 
milder than with adults and that its course is shorter. It may last 
only a few weeks but at times remains for several years. 

The prognosis is relatively good. The mortality from recorded cases 
has not been more than 10 per cent, while recovery is the rule. There 
may remain indefinitely a slight degree of exophthalmus and enlarge- 
ment of the thyroid and a tendency to cardiac palpitation with tachy- 
cardia. 

The treatment should be directed toward securing, for a time at 
least, complete mental and physical rest. Everything tending to excite 
or irritate should be avoided. It is best to remove the child from 
contact with other children. Prolonged warm packs may assist in 
producing rest and in inducing sleep which should be encouraged in 
every way. As the nervousness diminishes mild exercise may be indulged 
in and according to the improvement of symptoms the normal regime 
gradually may be resumed. Studies, school attendance and contact 
with other children should only be allowed after many weeks or months 
and when a nearly normal condition has again been reached. The use 
of drugs, except occasionally, and for the relief of special symptoms, 
has no place in the treatment. Surgical measures are only to be con- 
sidered when prolonged medical treatment has failed and when the 
progress of the disease is such as to threaten the life of the child. The 
indications for the various forms of operation are the same as with 
adults. 

HYPERTHYROIDISM 

Much more common than fully developed Graves' disease is the 
condition which is to be referred to a moderate increase of or perverted 
function of the thyroid gland. To this the term hyperthyroidism is 
applicable. The condition is found mostly in girls and usually between 
the eighth and fifteenth years. Several children in the same family 
may suffer from the condition and it usually occurs in distinctly neuro- 
pathic children. The chief symptoms are restlessness, irritability and 
nervousness. The children are constantly active. They are apt to be 
irritable and cry and laugh readily. They sleep badly and complain 
frequently of headache and of cardine palpitation, especially upon exer- 
tion. Their appetite and digestion are usually good hut there may he 
for some weeks or months moderate loss, of weight and strength, A mild 



890 DISEASES OF THE DUCTLESS GLANDS 

degree of anemia is often present. Physical examination reveals in 
the majority of instances a slight enlargement of the thyroid gland 
which does not pulsate. Exophthalmus, beyond a slight staring ex- 
pression of the eyes, is not found, and von Stelwag's and von Graefe's 
signs are absent. The heart's action is slightly exaggerated and rapid. 
Cardiac palpitation may be a cause of complaint. The hands of these 
children are apt to be constantly moist. The symptoms may last for 
some weeks or months. They usually disappear entirely, especially if 
proper measures are instituted, and in girls when menstruation becomes 
established. A marked increase in the severity of the symptoms is un- 
usual, and the development of severe hyperthyroidism or Graves' disease 
from a mild form is rare. The treatment is the same as for Graves' dis- 
ease — rest, quiet and removal from an exciting or irritating environment 
should be provided for. Tea, coffee and alcohol are to be entirely 
interdicted. The treatment is hygienic and not medicinal. 



DISEASES OF OTHER DUCTLESS GLANDS 

A large number of conditions which cannot be classified among any 
of the generally recognized diseases have been ascribed to disturbances 
of function of the various endocrine or ductless glands. It is necessary 
in most of these instances to assume that the disturbance is only func- 
tional since pathological changes are either entirely wanting or are 
recorded in an insufficient number of cases to establish a connection 
between the symptoms and the condition to which the symptoms are 
attributed. 

Lesions of the pituitary gland seldom if ever produce acromegaly in 
children. Tumors of this gland or in its neighborhood may give rise to 
a group of symptoms known as "Frohlich's syndrome," i. e., adiposity, 
delayed sexual development, increased sugar tolerance, and sometimes 
associated mental dulness. 

Tumors of the pineal gland are in rare instances associated with 
precocious sexual development; tumors of the adrenals, more frequently. 
The exact association of the interference with the function of the glands 
and the precocious development is difficult to determine since the over- 
whelming majority of pineal tumors cause no such symptoms and 
because experimental removal of part or all of these glands in animals 
does not produce comparable effects. 

Polyglandular disturbances affecting two or more of the ductless 
glands are held accountable for many conditions, particularly the various 
types of infantilism. This is an attempt, in the absence of any other 
explanation, to ascribe a train of symptoms to a number of organs whose 



STATUS LYMPHATICUS 891 

individual functions are largely unknown. At the present time our 
knowledge regarding the normal function of these glands and the results 
of their disturbed function is so very indefinite that it seems unsafe 
to ascribe to them, individually or collectively, an exact clinical impor- 
tance. As yet this has not been established. 

The use in practice of the various glandular extracts, though prev- 
alent and increasing, has been in our experience with most unsatis- 
factory results. It can, however, be definitely stated that their adminis- 
tration by mouth is free from danger. 



DISEASE OF THE THYMUS 
STATUS LYMPHATICUS 

The term status lymphaticus is applied to a very definite pathological 
condition which is associated with clinical manifestations, less constant 
and not characteristic. The relation between the lesions and the symp- 
toms is little understood, and almost nothing is known of the etiology 
or pathogenesis. The most striking part of the lesion is the great 
enlargement of the thymus gland, with which is found a hyperplasia 
of the lymphoid tissues throughout the body, more marked than is seen 
in any other condition in childhood. The two most frequent symptoms 
are convulsions and attacks of asphyxia. 

The status lymphaticus is most often seen between the sixth and 
twelfth months, but may be met with in children of any age. Enlarge- 
ment of the thymus to a degree sufficient to be regarded as pathological, 
is not an infrequent condition. An association with rickets is often 
observed, but it is doubtful whether this is anything more than a coin- 
cidence. 

Since the large thymus is so important a lesion, it is desirable to 
know what may be regarded as normal. The most extensive observations 
upon this point have been made by Bovaird and Xicoll, who weighed 
the thymus in 495 consecutive autopsies in children under five years. 
They found that the weight was greatest at birth, the average being 
7.7 grams. After this time the change in weighl was very slight for 
the period of five years, the average for the entire t9S observations being 
5.9 grams, which was about the same as the average for cadi of the years 
taken separately. Excluding cases in which the organ was bo large as to 
be considered abnormal (10 grams or over), the average weight at birth 
was 6.5 grains; during infancy and early childhood. 1 gin in-. The 
results of these observations do not differ essentially from those of Pried- 
leben, which have been so extensively misquoted. It may therefore he 



S92 



DISEASES OF THE DUCTLESS GLANDS 



assumed that the average weight of the normal thymus at birth is from 
G to 7 grams; from birth to five years, from 3 to 4 grams. Anything 
over 10 grams may be considered abnormal. 

In the status lymphaticus the thymus is often from five to ten times 
larger than normal. In the marked cases its weight is from 30 to 40 
grams; in the less marked cases from 15 to 20 grams. The appearance 
of the enlarged thymus is well shown in the accompanying illustra- 




I'm;. 139. — Enlarged Thymus. The lungs, heart, and thymus are shown in the picture. 
I The lungs have been turned back, showing the two lateral lobes of the thymus over- 
lapping the heart; the central lobe, above, covers the trachea. History. — Breast fed, 
male child, nine months old, well developed; ill less than twenty-four hours; dyspnea, 
slight cyanosis, with death from asphyxia. T. 103° F. Autopsy.— Besides the 
large thymus there were present the general lesions of the status lymphaticus to a 
marked degree; lungs deeply congested. 



tion (Fig. 139). A thymus of the size shown weighs about 45 grams, 
or 1J ounces. In this instance it was nearly as large as one of the lobes 
of the lung. In general appearance, the enlarged thymus is rather more 
vascular than normal, but other than hyperplasia, shows no constant or 
essentia] changes, either by gross or microscopical examination. 

The lymph nodes of the tracheobronchial region are greatly enlarged. 
often to the Bize of small cherries, and are found in greal clusters. Those 



STATUS LYMPHATICUS 803 

of the mesenteric region may be still larger. Feyer's patches are very 
prominent, and the solitary follicles of the small intestine appear like 
mustard seeds upon the folds of the mucous membrane. Those of the 
colon are also very prominent. The lymphoid tissues about the pharynx 
and all the lymph nodes of the body are greatly hypertrophied. The 
spleen is usually enlarged, with prominent follicles. There are no other 
constant changes. Those present are usually accidental, depending upon 
the cause of death. 

Symptoms. — In very early infancy this is one of the explanations of 
sudden death occurring after slight causes, and in some cases without 
any apparent cause. Death is often attributed to overlying, to asphyxia 
from aspiration of food, or to some other condition affecting respira- 
tion, or infants are simply found dead in their cribs without evidence 
of anything abnormal in history or symptoms. 

Even in children who live until they are several months, sometimes 
several years, old, there may be nothing in their condition to indicate 
the presence of the status lymphaticus until something acute occurs. 
This may be in the nature of a slight accident, a surgical operation 
of a trivial character, the administration of an anesthetic, or some acute 
disease, frequently one affecting the respiratory tract. The symptoms 
associated with this condition are frequently of a nervous character, 
usually attacks of convulsions, or they affect the respiration, causing 
paroxysms of dyspnea, cyanosis, and even asphyxia. A frequent history 
is somewhat as follows: A child previously regarded as healthy, often 
well nourished and perhaps entirely breast fed, is taken with convulsions 
followed by high fever, preceding which there may have been some 
pulmonary symptoms suggesting a commencing bronchopneumonia. The 
convulsions recur at short intervals; the temperature remains steadily 
high ; the signs in the lung are few and not proportionate to the other 
symptoms; and death occurs in from twelve to thirty-six hours often 
in convulsions. 

In other cases convulsions are absent and the prominent symptom 
is asphyxia, which comes in paroxysms and may be so complete as to 
lead to the suspicion of laryngeal obstruction. If intubation or trache- 
otomy is performed, no relief follows. The child may die in the first 
severe attack, which may be preceded for a few hours by moderate 
dyspnea, or may come on almost without warning. It is more frequent, 
however, for the first attack to be less severe, the child perhaps being 
resuscitated with some effort, after which he may breathe almost as well 
as usual. In a few hours the attack of asphyxia is repeated ; after sev- 
eral of these, each one growing more severe, death occurs. In these 
cases the elevation of temperature is usually slight and may he wanting. 
Symptoms similar to the above hut of less severity and resulting in 
30 



804 DISEASES OF THE DUCTLESS GLANDS 

recovery would suggest status lymphaticus, although the diagnosis ean 
not be established. 

The cause of the symptoms is not definitely known. The asphyxia 
has been ascribed to pressure of the large thymus upon the lungs, the 
trachea, the pneumogastric nerves, or the auricles of the heart. Pres- 
sure would seem at times to be a factor in the production of the dyspnea, 
but apparently not the chief one. Constant dyspnea, even with a very 
large thymus, has never in our experience been present. It does not 
seem that the large thymus produces its symptoms mechanically. 

There is another group of cases, perhaps the largest of all, in which 
there are no symptoms distinctly referable to the status lymphaticus, 
and yet this condition appears to be the factor which determines the fatal 
outcome of what was apparently an infection or an inflammation of only 
moderate severity. What is seen here is simply a greatly diminished 
resistance to disease. In these cases it is only the autopsy which reveals 
the explanation. 

Diagnosis. — The diagnosis of enlarged thymus is possible only by 
physical examination, the symptoms being too indefinite to be relied 
upon. In percussing the thymus the child should be placed upon the 
back and the neck completely extended. In some cases of marked en- 
largement a definite area of dulness can be made out over the base of 
the sternum. The X-ray is also of distinct value, the shadow being 
sometimes so marked especially to the right as to be conclusive. Unfor- 
tunately in many, perhaps most of the cases, both these means of diag- 
nosis give probable results only, so that while we may suspect the condi- 
tion we can not do more. Marked enlargement of the tonsils and the 
adenoids exists so frequently without thymus enlargement, that this can 
hardly be regarded as suggesting the condition. The hyperplasia of the 
tracheobronchial or mesenteric lymph nodes or of the follicles of the 
intestine produces no especial symptoms. 

Prognosis. — While this condition apparently may exist for an in- 
definite time without producing any symptoms, it undoubtedly often 
determines a fatal outcome of what might otherwise have been a mild 
illness or a trivial accident. It is especially important in connection 
with acute bronchitis and bronchopneumonia, with attacks of convul- 
sions, with the shock of slight operations, and with the administration of 
anesthetics, particularly chloroform. It is one of the most frequent 
explanations of unexpected death from such slight causes as an explora- 
tory puncture or even a hypodermic injection. 

At present no known treatment has any influence upon the condi- 
tion. There is experimental evidence that the X-ray produces involu- 
tion of the thymus gland; but that it cures the condition of status 
lymphaticus in the human subject has not yet been established. 



OSTEOGENESIS IMPERFECTA 895 

CHAPTER IV 

DISEASES OF THE BOXES AXD JOINTS 
OSTEOGENESIS IMPERFECTA 

(Osteopsathyrosis-Fragilitas Ossium) 

Of the etiology of this rare affection, little is known. No especial 
disease can he held responsible for it and the condition is not usually 
hereditary. It is at times, however, found in certain families associated 
with a peculiar blue coloring of the sclerotica, and in such circum- 
stances is distinctly hereditary. In affected families those children 
with a tendency to fractures have blue sclerotica, but not all the chil- 
dren have this weakness of the bones. The explanation of the associa- 
tion is not clear. 

Despite the etiological uncertainty the pathological changes are 
characteristic. They are found only in the bones but are present in 
all the bones, those formed in membrane as well as those formed from 
cartilage. The cartilage itself is in no way affected so that the growth 
of the bones in length is normal. The formation of bone, however, 
both from the periosteum and in the shaft, is greatly interfered with 
on account of deficient numbers and activity of the osteoblasts. The 
result is that the bony trabeculae are infrequent and small. Thus the 
bones are thin and very fragile. Xo changes have been demonstrated 
in any of the ductless glands. 

The most striking feature of the disease is the fragility of the 
bones — the ease with which they undergo fracture. This takes place 
even in intrauterine life, so that infants are at times born with forty or 
fifty fractures and with greatly distorted extremities (Fig. 140). The 
majority of children with osteogenesis imperfecta are born dead or die 
shortly after birth. The bones of the skull are frequently so slightly 
formed that the whole cranium is soft and of a parchment-like consist- 
ency with widely separated sutures. As the result of the numerous 
intrauterine fractures, distinct shortening of the extremities may have 
taken place. Thus there may be at birth a certain similarity to the 
configuration of chondrodystrophy. 'Hi is shortening can also be made 
out by the X-ray; but confusion of the two is impossible for the density 
of the bones is always greatly diminished and multiple fractures arc al- 
most always in evidence. Any of the bones, including the ribs, may be 
fractured. 

Those infants who survive show a greater or less marked fragility 
of the bones. Fracture sometimes occurs from ordinary handling which 





896 



CHONDRODYSTROPHY S97 

it is quite impossible to prevent, or in other instances only when a 
moderate degree of force is applied. Callous formation is slight and 
the process of repair of longer duration than with the normal child. 
In exceptional instances the fragility of the bones is only manifested 
after several years so that there may be no suspicion of any trouble until 
a number of fractures occur as the result of very little traumatism. 
Following the numerous fractures and the difficulty of healing, there 
is usually greater or less shortening and deformity of the bones. It 
may be extreme. 

The progress of the disease varies much in the different cases; in 
some children there is no tendency to improvement; in others, usually 
in those in which the fragility is considerably less, there seems to be 
improvement in the condition of the bones so that abont the time of 
puberty, or shortly after, fractures do not occur except when there is 
the application of unusual force. There is no known treatment that 
influences either the severity or the course of the disease. 



CHONDRODYSTROPHY 

(Achondroplasia) 

This rather rare condition, often improperly called congenital or 
fetal rickets, is the cause of some of the most marked examples of 
dwarfism known. It was recognized as an abnormality by the early 
Egyptians and has figured in art in various ways since that date. 
Paintings show that many of the old court jesters were of this type. 
Because of their striking appearance, these dwarfs have always excited 
much curiosity and interest. 

The causes of chondrodystrophy are unknown; only in rare cases 
has any hereditary connection been traced. The pathological process 
begins in fetal life and consists in a disturbance of the normal ossifica- 
tion of primary cartilage. It affects endochondral ossification only, 
never intramembranous ossification. The flat bones, therefore, escape 
entirely. The vertebrae are only slightly affected while the long bones 
of the extremities suffer most but not equally, though the disturbance 
is symmetrical. The humeri and femora are almost always the seat 
of the greatest interference with growth. One of the most striking 
changes in the skull is the synostosis or early ossification of the tribasilar 
bone; this is formed of two parts of the sphenoid and the sphenoidal 
process of the occipital bone. Normally this ossification does not take 
place until adult life; in children with chondrodystrophy it often begins 
in utero. This prevents a normal expansion at the base of the skull, and 



S9S 



DISEASES OF THE BONES AND JOINTS 





Fig. 141. — Skull in Chondrodystrophy, Showing Frontal Prominence and Prog- 
nathism. Girl six years old. 

the brain, as it grows, is thus crowded upward and forward, causing the 

great prominence of the forehead (Fig. 
141). The upper jaw appears very prom- 
inent on account of the depression at the 
root of the nose. 

In the long bones there is a marked in- 
terference with the normal proliferation of 
cartilage cells. This interference may be 
seen in all degrees. In some cases a peri- 

0^— ■ osteal lamella pushes its way between the 
^ m ^F^' epiphysis and diaphysis, still further re- 
m y m B H stricting the growth of the long hones. As 
bone formation beneath the periosteum goes 
on normally, the bones in chondrodys- 
trophy are thick as well as short. 

Symptoms. — The majority of children 
suffering from this condition are either 
born dead or die shortly after birth. Those 
who survive are delicate during infancy, but 
afterward may become strong and healthy. 
The most striking thing about their appear- 
ance is the very short legs and arms as compared with the length of the 
body. At birth the arms in many eases do not reach to the waist line, 





Fig. 142. — Normally De- 
velopbd Long Bones of a 
Fetus Compared with 
THOSE of Chondrodys- 
trophy. (Spillmann.) 



CHONDRODYSTROPHY 



899 



and the length of the body may be less than the circumference of the 
head. The epiphyses appear somewhat enlarged, the abdomen is prom- 
inent, the skin of the extremities is in deep 
folds, the soft parts seeming to be much too 
abundant for the shortened bones (Fig. 143). 
In infancy these children are often quite fat. 
The facial expression is characteristic. There 
is usually a deep depression and flattening at 
the base of the nose, with a very marked prom- 
inence of the forehead. The head may not 
only seem large, but by measurement may be 
one or even two inches above the normal aver- 
age. An erroneous diagnosis of hydrocephalus 
is often made in the early stage. Dentition is 
slightly later than normal, but not more so 
than is seen in moderate rickets. Marked re- 
laxation of the ligaments and rather feeble 
muscular power often delay walking until the third or fourth year. 
If the head is large, the fontanel may not close till the fourth or fifth 
year. .The so-called "trident hand" 
is characteristic. The fingers are very 
short and of nearly equal length, and 
an angular separation is seen at the 
second joint (Fig. 144). 




Fig. 143. — Chondrodystro- 
phy. Infantile Figure. 
(Marie.) 




Fig. 144. — Characteristic Hand of 
Chondrodystrophy. (Marie.) 




Fig. 145. — A, Normally Developed Boy, 
Age Eight Years. B, Typical Chon- 
drodystrophy. Age Eighteen Years 
(Marie.) 



These dwarfs are usually somewhat subnormal in their mental de- 
velopment but cannot be classed as defectives. They are good-natured, 



000 DISEASES OF THE BONES AND JOINTS 

often amusing, easily controlled, and frequently live to a great age. 
With advancing years the figure assumes a very peculiar and charac- 
teristic appearance. The prominent hips, with the marked lordosis, 
shortened extremities, and late bowing of the legs, present a striking 
picture (Fig. 145). The maximum height attained is often not more 
than three and a half or four feet. Although while young of feeble 
muscular power, later in life they often become very muscular. When 
adult life is reached the sexual powers are normal; if the women 
become pregnant, Cesarian section is almost always required on account 
of deformity of the pelvis. 

In infancy, chondrodystrophy is often confounded with rickets, hy- 
drocephalus, cretinism and osteogenesis imperfecta; but its features arc 
so characteristic that the mistake can hardly be made if the child is 
carefully examined. In severe osteogenesis imperfecta the femora may 
be very short but the association with multiple fractures determines 
the diagnosis. No known treatment has any influence upon the condi- 
tion. The use of the thyroid extract is entirely without effect. 



ACUTE ARTHRITIS OF INFANTS 

The terms acute purulent synovitis, acute epiphysitis, pyemia of 
bone, and acute osteomyelitis, have all been applied to this condition. 
The disease is really a form of pyemia. The causes and lesions may 
differ considerably in the different cases, but clinically they all have 
certain features in common, viz., an acute joint inflammation with sup- 
puration. 

The acute arthritis of infants is essentially a disease of the first year, 
and is much more frequently seen in the first six months. The inflam- 
mation may begin in the joint, at the epiphyseal junction, or in the 
medullary canal ; but, however it may start, the joint is soon invaded. 
The nature of the arthritis varies somewhat with the exciting cause. 
When it is due to the gonococcus, it is usually confined to the joint; 
there is in most such cases a superficial inflammation involving the 
synovia] membrane, but rarely leading to destructive changes in the 
cartilage, ligaments, or bone. When it is due to the streptococcus or 
staphylococcus, it may begin elsewhere than in the joint, which, how- 
ever, Is usually soon involved, and complete disorganization may follow. 
It may also result in a diffuse osteomyelitis, in a subperiosteal ab- 
scess, or a separation of the epiphysis. As a late result there may be a 
pathological dislocation or a 'Hail joint''; less frequently there is 
ankylosis. 

Etiology.— -The cause of acute arthritis in infants is the entrance 



ACUTE ARTHRITIS OF INFANTS 901 

of pyogenic organisms into the circulation. In cases occurring in the 
newly born the most frequent organism is the streptococcus, at other 
times the gonococcus. Less frequently are found the staphylococcus or 
the pneumococcus and very rarely the influenza bacillus. In most cases 
occurring during the first two months of life, the portal of entry is 
the umbilical cord, though infection may take place through the 
skin, conjunctiva, genital tract, or the mouth. In the cases developing 
later it is often difficult to determine the point of entry, especially 
when the cause is the gonococcus. Of 26 cases of acute gonococcus 
arthritis observed in the Babies' Hospital, only 2 occurring during the 
first month could be classed as infections of the newly born. The cases 
were observed during a hospital epidemic of gonococcus vaginitis, and 
yet 19 were in male children, in no one of whom was there any genital 
lesion, and in only one was there conjunctivitis. Of the 7 cases occur- 
ring in girls, only 2 had vaginitis. The portal of entry in these cases 
could not be definitely determined. We have also observed isolated cases 
of gonococcus arthritis in the course of a gonococcus pyemia when it 
was impossible to determine the mode of entrance of the organism into 
the circulation. 

Symptoms. — General symptoms often precede the local ones. In the 
most acute cases the temperature is high and widely fluctuating, accom- 
panied by other symptoms of a severe infection. The earliest local 
symptoms are pain and tenderness, soon followed by swelling, which may 
develop quite rapidly in a single joint, or in several joints simultane- 
ously. In those superficially situated there is redness of the skin, and 
fluctuation may be evident in three or four days. In cases coming on 
more gradually the temperature may be only from 100° to 102° F., and 
suppuration may not occur for two or three weeks. In the most severe 
cases the progress is rapid, one joint after another being involved, with 
general symptoms of pyemia, and death may occur in a week or ten days, 
usually from some visceral inflammation, pneumonia, pericarditis, or 
meningitis. In such cases blood cultures usually show the presence of 
the organism to which the infection is due. In the less severe type, 
which is more often seen, the symptoms may last for five or six weeks. 
When pus is not evacuated extensive burrowing often takes place. 

In Townsend's collection of 73 cases, the joints were involved in the 
following order: hip, in 38; knee, in 27; shoulder, in 12; wrist, in 5; 
ankle, in 4; elbow, in 4; small joints, in 4. In three-fourths of these 
cases only a single joint was affected. In the 20 gonococcus cases 
referred to the localization was as follows: finger or metacarpus, in 
20; ankle, in 18; knee, in 17; wrist, in 12; toe or metatarsus, in 10; 
shoulder, in 9; elbow, in 5; temporo-maxillary, in 1; hip, in 1. The 
average number of joints involved was 4 or 5, the largest number being 



902 DISEASES OF THE BONES AND JOINTS 

8. The tendency of the gone-coccus infections to involve the small joints 
is striking. 

Diagnosis. — When several joints are involved, the disease is often 
mistaken for acute articular rheumatism, which, however, at this age is 
so rare that it may be ignored. Blood cultures are of diagnostic value. 
Syphilitic epiphysitis resembles it in the localized tenderness and dis- 
ability; but the rapid swelling and the severe constitutional symptoms 
are lacking. 

Treatment. — Cold applications or wet dressings may be useful in 
relieving the symptoms. In some cases, most frequently when the cause 
is the gonococcus, the inflammation subsides without suppuration. In 
infections due to other organisms, suppuration almost invariably occurs 
and early free incision should be made, followed by fixation of the 
joint. The results depend in no small degree upon the promptness with 
which the pus is evacuated. In the gonococcus cases there may be com- 
plete recovery. In most of the others the functions are impaired. 

The use of vaccines is to be advised in all these cases. The best 
results are seen in infections due to the staphylococcus and next, those 
due to the gonococcus. In such cases, autogenous appear to have little 
if any advantage over stock vaccines. Injections should be repeated every 
five or six days in increasing doses. 



CHRONIC ARTHRITIS 

{Atrophic Arthritis, Still's Disease) 

Under the heading of chronic arthritis are probably included a 
number of chronic joint affections which as yet we are unable to separate, 
They all have as a common characteristic a crippling of the joints, not 
on account of primary changes of the bones or cartilages but as the 
result of lesions of the synovial membrane, capsule, ligaments and peri- 
articular structures which may later cause secondary changes in the 
bone and cartilage. As there is no sharp line of demarcation between 
these conditions it is convenient to discuss them all under one heading. 

Etiology. — The frequency with which these forms of arthritis begin 
in the young is very striking. They are often seen in children under 
I luce years of age, and the histories of those seen later often date back 
to tli is period of life. Boys are rather oftener affected than girls. 
While do history of infection may be obtained, in quite a number of 
instances the disease immediately follows or occurs shortly after some 
infectious disease or suppurative process. Scarlet fever and measles, 
particularly the former, are the exanthemata after which chronic arth- 



CHRONIC ARTHRITIS 903 

ritis is most often seen. Demme has described, and we also have 
observed, very severe progressive arthritis following scarlet fever. The 
suppurative process which precedes the arthritis may be anywhere in 
the body — in the pleural cavity, the bones, the accessory nasal sinuses, 
the teeth or the tonsils. A history of rheumatism is not infrequently 
obtained. It is doubtful if at this age it is really true rheumatism, but 
rather an unusually acute onset of the arthritis with fever. Hemophilia 
with hemorrhages into the joint may be followed by severe joint lesions, 
but these are quite distinct from the condition now under considera- 
tion. Xor has this form of arthritis a close connection with syphilis or 
tuberculosis. 

Pathology. — Early in the disease and for a considerable time the 
joint surfaces and the bones are not involved. The lesion is chiefly in 
the synovial membrane, joint capsule, ligaments and surrounding struc- 
tures. The synovial membrane is thickened; its villous processes are 
hypertrophied and the membrane is hyperemic and edematous. After a 
time it becomes thickened by the growth of new tissue. The same condi- 
tion occurs in the capsule. The joint itself may contain fluid; this is 
usually quite clear. Later, the cartilages may be somewhat eroded at 
their edges by the hypertrophied villi of the synovial membrane. Very 
rarely, and only after many years, there may be fibrous or even bony 
ankylosis. Except for this, the only changes in the bones themselves are 
atrophic. They show all grades of osteoporosis. 

In a certain number of instances, changes in other viscera are 
found. The spleen and lymphatic glands may be increased to several 
times their normal size, but they show nothing characteristic. The 
lesion is merely hyperplasia. Very rarely, without apparent cause, 
general amyloid degeneration of the viscera is found. 

Symptoms. — The onset may be acute with fever and with involve- 
ment of the joints almost coincident with the fever, or there may be 
swelling and articular pain and tenderness with no fever whatever. At 
other times there may be general symptoms for many weeks before the 
joints are found to be involved. We have seen one boy who had fever 
for nearly three months before the involvement of his wrists, which 
was followed rapidly by that of his ankles and knees. Xo matter what 
the mode of onset the joints usually involved are, in order of frequency, 
those of the carpus and phalanges, the wrists, elbows, ankles, knees, hips 
and the cervical spine. Earely other joints such as the sternoclavicular 
and the maxillary are implicated in the process. The articular lesions 
are usually symmetrical, but may differ in severity upon the two sides. 
The joints are swollen and are moderately tender to the touch ; on palpa- 
tion they give a somewhat doughy sensation. They frequently contain 
fluid but usually not a large amount. The fluid may disappear and 



904 DISEASES OF THE BONES AND JOINTS 

re-accumulate rapidly. The appearance of the fingers is very characteris- 
tic, the first interphalangeal joint being the one earliest and most severely 
affected. The articular involvement causes flexion of the joints to a 
greater or less extent and this deformity increases with the progress of 
the disease. The pain is not great, nor is there tenderness upon pressure, 
but attempts to bring the joints into their normal position by active or 
passive motion are impossible both on account of pain and the changes 
in the peri-articular structures. The joints are often covered by fine, 
shiny skin. There may be no fever whatever, and only the articular swel- 
lings. In other circumstances, fever may be a prominent symptom. 
There may be a persistent elevation of temperature, a degree or two above 
normal or for weeks there may be daily exacerbations and remissions of 
several degrees. At times the fever disappears and may be absent for 
months, but when it has once been a feature of the disease it is likely 
to return. With the febrile form of arthritis there is usually enlarge- 
ment of the superficial lymphatic glands, chiefly the inguinal and 
axillary. The cervical glands may also be involved and not infrequently 
the epitrochlears. The spleen is often enlarged and rarely the liver 
also. There may be albuminuria and casts in the urine. With all 
forms of chronic arthritis the general condition of the child suffers. 
There is usually a moderate degree of secondary anemia which is most 
marked in the febrile form. To the form of arthritis with fever and 
enlargement of the spleen and lymphatic glands, the name "Still's dis- 
ease 7 ' is frequently applied. 

An examination with the X-ray shows a thickening of the peri- 
articular structures, often distention of the joint, and a greater or 
less degree of osteoporosis. No osteophytes can be demonstrated. 

There is a great difference in the rapidity with which crippling of 
the joints occurs. In one case as much damage may be done in a few 
weeks as occurs in j^ears in another. Eventually motion in the extremi- 
ties may be nearly impossible with the joints fixed in positions of 
extreme deformity. 

The course is usually progressive from bad to worse. The crippling 
becomes greater and greater though the general health may remain 
fair. Death, in such circumstances, is due to some intercurrent 
disease, very rarely to amyloid degeneration of the viscera. If the 
cause of the disease can be removed, the prognosis is good so far as 
further deformity is concerned. Even when no cause can be discovered, 
arrest of the disease may occur, and at times recovery is almost complete, 
but this result is so rare as hardly to be expected. 

Treatment. — This should always include a careful search for any- 
thing that might act as an etiological factor. Especially should septic 
processes in the tonsils, in the accessory sinuses and in the teeth be 



TUBERCULOUS DISEASE OF THE BONES AND JOINTS 905 

sought. Unless the cause can be removed, treatment is merely pallia- 
tive. The patient should be placed under the best hygienic conditions 
with as much life out of doors as possible. Apparatus should not be 
worn except to prevent deformity and to assist in walking. 



TUBERCULOUS DISEASE OF THE BONES AND JOINTS 

The chronic forms of tuberculous bone disease, on account of their 
insidious onset and the frequency with which they simulate other dis- 
eases, more frequently fall, in the early stage at least, into the hands of 
the physician than into those of the general or orthopedic surgeon. All 
that will be attempted in this chapter will be to outline in a general 
way the most important forms — viz., disease of the vertebrae, hip, and 
knee — dwelling particularly upon the early symptoms and diagnosis. 
For their fuller discussion, particularly as to the details of treatment, 
the reader is referred to text-books on general or orthopedic surgery. 
The causes are the same, and the lesions are very similar in all forms, 
and will therefore be considered together. 

Etiology. — The age at which tuberculosis of the bones most fre- 
quently begins, is from the third to the eighth year, it being compara- 
tively rare before the end of the second year. The sexes are affected 
with about equal frequency. Tuberculous bone disease may occur in a 
child who has previously been in apparent health, but more often in one 
who has been reduced by some previous illness, especially one of the infec- 
tious diseases; of these, it most frequently follows measles and whooping- 
cough. Of seventy-one cases in children investigated by Park and 
Krumwiede, or collected by them, the bacillus was of the human type 
in sixty-eight and bovine in but three instances. 

A family history of tuberculosis is present in a large number, but 
by no means in a majority, of the cases. Like tuberculosis of the cer- 
vical glands, it is rarely preceded by other tuberculous processes, al- 
though it may be followed by them. It usually appears as an example 
of primary infection ; but it is quite impossible that such should actually 
be the case. There has previously been a latent focus of tuberculosis 
elsewhere in the body. In many cases disease of the bronchial glands 
has been demonstrated by autopsy. Infection from those or from other 
tuberculous lymph glands is the most frequent point of origin of infec- 
tion in cases of bone disease. 

Traumatism is often an exciting cause, and it may determine the 
site of the disease. 

Lesions. — The tuberculous joint diseases of childhood are, as a rule, 
secondary to disease of the bones. Hip-joint disease usually begins in 



906 DISEASES OF THE BONES AND JOINTS 

the head of the femur, and knee-joint disease in one of the condyles; 
ankle-joint disease in the lower epiphysis of the tibia, etc. 

The frequency with which disease is seen in the different locations is 
shown by the following table, which gives the number of cases of eacli 
form applying for treatment at the Hospital for Euptured and Crippled, 
New York, during ten years : 

Spine 2,145 cases, or 37 . 5 per cent. 

Hip 1,937 " " 34.0 « " 

Knee 1,222 " "21.5 " " 

Ankle or tarsus 255 " " 4.5 " * 

Elbow 71 " " 1.2 " ■ 

Wrist 50 " " 0.9 " " 

Shoulder 24 " " 0.4 " " 

Total • 5,704 100.0 

The character of the bone disease upon which chronic joint disease 
depends is generally a primary ostitis, which affects the articular ex- 
tremities of the long bones, usually beginning near the epiphyseal line; 
in the short bones it is a central ostitis. The stages in the process are, 
congestion, swelling, and cell infiltration, followed by caseation, and 
frequently by softening and suppuration. In the early stage, the 
bone is slightly enlarged, and on section one or more yellowish foci of 
disease are seen. The disease may be arrested in this stage, encapsula- 
tion of the inflammatory products taking place ; or it may continue until 
there is a more or less extensive breaking down or disintegration of the 
affected bone. As the disease extends there are involved the periosteum, 
the articular cartilage, and finally the joint itself. Abscess may form in 
the joint or in the soft parts surrounding the bone. The process is quite 
analogous to tuberculous disease of the lung. As the disease advances 
ligamentous attachments are loosened, and displacement of the parts 
occurs with the production of deformity, due partly to muscular con- 
traction and partly to the weight of the body. The inflammatory proc- 
ess, with its resulting disintegration, generally goes on to a certain 
point, where it is arrested. Gradually the broken-down bone substance 
is separated and thrown off in small particles in the discharge, and a 
reparative process begins, with the formation of healthy bone. Where 
joint structures have been destroyed, cure takes place by bony ankylosis. 
Sometimes the disease finds its way to the surface without involving the 
joint; at other times the disease may be arrested, and its products be- 
come encapsulated within the bone. Inflammation of the joint may 
occur by a gradual extension of the inflammatory process, or by a sud- 
den perforation of the articular lamella. As a result of extensive dis- 
ease, all the joint structures may be affected — the synovial membrane, 



CARIES OF THE SPINE 907 

ligaments, articular cartilages, and the cellular tissue surrounding the 
joint. The process of disintegration and that of repair are both very 
chronic and measured by months or years. The entire course of the 
disease is from one to ten years, three years being about the average dura- 
tion. In the great proportion of cases but one joint is involved, although 
it is not infrequent in hospitals to see two, three, and sometimes four of 
the large joints affected in the same patient. 

Secondary Lesions. — Abscesses form in a considerable proportion of 
the cases, and often burrow a long distance before they reach the surface. 
Amyloid degeneration of the liver, spleen, and kidney, and sometimes of 
the intestines, occurs as the result of the prolonged suppuration, chiefly 
in connection with disease of the hip or spine, occasionally with that of 
the knee. General or localized tuberculosis, particularly tuberculous 
meningitis, may develop at any time and prove fatal. 

Caries of the Spine — Pott's Disease 

This consists in a tuberculous inflammation of the bodies of the ver- 
tebrae, usually beginning in the central portion and extending to the 
periosteum, ligaments, cartilages, and, in fact, to all the contiguous 
structures. Secondarily it involves the membranes of the cord, the 
roots of the spinal nerves, and even the cord itself. The number of ver- 
tebrae usually affected is from two to five. The gross appearance of the 
lesion in a well-marked case is shown in the accompanying cut (Fig. 
146). After the bodies of the vertebrae have become softened and par- 
tially broken down by disease, the pressure from the superincumbent 
weight of the body causes them to fall together and produces a back- 
ward displacement of the spinous processes, giving rise to the deformity 
known as kyphosis, which in its extreme form is popularly known as 
"hunchback." 

Any part of the vertebral column may be affected; but the disease 
is most frequent in the dorsal region, as shown by the following statistics 
from the Hospital for Euptured and Crippled: Of 2,143 cases, 72.5 
per cent affected the dorsal region, 15.3 per cent the lumbar region, 
and 12.2 per cent the cervical region. 

Symptoms. — The onset is gradual, often insidious, and the early 
symptoms are frequently overlooked or misinterpreted. The case may 
go on for weeks or even months before the true nature of the disease 
is recognized, which is often not until deformity has occurred. In 
nearly all cases, however, the early symptoms are sufficiently character- 
istic to enable a careful observer to make a diagnosis before the stage 
of deformity. 

The most constant early symptoms are: (1) pains caused by the 



908 



DISEASES OF THE BONES AND JOINTS 



irritation of the nerve roots and referred to various parts of the body, 
following the distribution of the spinal nerves; (2) rigidity of the 
spine from muscular spasm, this being an attempt to prevent motion 
at the seat of disease; and (3) the assumption of various postures cal- 
culated to relieve pressure upon the diseased vertebral bodies. Some- 
times the first symptoms are those of pressure-paralysis; at others they 
are the local signs of abscess. In addition to the local symptoms men- 
tioned, there is usually disturbed sleep, often accompanied by moaning. 

Cervical Disease. — The pains are often 
felt above the point of disease, frequently in 
the form of occipital neuralgia; sometimes 
they are referred to the front or the side of 
the neck. They may be so frequent and so 
severe that the face assumes a constant ex- 
pression of anxiety or distress. In other 
cases pain is excited only by an attempt at 
movement. The muscular spasm most fre- 
quently takes the form of slight torticollis, 
sometimes of slight opisthotonus; sometimes 
there is simply a fixation of the head by a 
tonic spasm of all the muscles of the neck; 
both active and passive motion is resisted, 
and any movement may be so painful that 
the child involuntarily steadies his head with 
his hands. These symptoms come on grad- 
ually and are persistent. Sometimes they are 
overlooked, and the first thing to attract at- 
tention is a progressive weakness in the lower 
extremities, which proves to be the beginning 
of paraplegia. Occasionally the first marked 
symptoms are those due to the formation of a 
retropharyngeal or a retro-esophageal abscess. 
The deformity from cervical disease de- 
velops much later than when the disease is 
located elsewhere. Usually the neck appears broadened or thickened in 
a nearly uniform way, and often the head seems to have settled down- 
ward upon the shoulders. In the lower cervical region a kyphosis is not 
infrequent; but in the middle and upper regions there is more often an 
anterior prominence, which may be felt in the posterior wall of the 
pharynx. 

Dorsal Disease. — The referred pains are now below the seat of dis- 
ease, and take the form of intercostal neuralgia or pain in the epigas- 
trium or the abdomen. They are often ascribed to cold, malaria, indi- 




Fig. 146. — Pott's Disease of 
the Upper Dorsal Re- 
gion. A vertical section 
of the spine, showing dis- 
integration of the bodies 
of the vertebrae and en- 
croachment upon the spi- 
nal canal. (From a patient 
dying in the Hospital for 
Ruptured and Crippled.) 



GABIES OF THE SPINE 909 

gestion, or worms. There is a disposition to assume the prone position 
while sleeping, and also to lean across a chair or the lap of the nurse. 
The child walks carefully, holding the spine erect and very stiff, and 
exhibits great caution in getting into or out of bed, or in rising from a 
recumbent position. In the beginning there may be a slight lordosis, or 
forward curve at the seat of disease, instead of the usual kyphosis or 
backward projection, but the latter soon takes its place, and with it is 
seen the compensatory lordosis in the lumbar region. 

Lumbar Disease. — The first symptoms here are often pain and lame- 
ness, referred to one of the lower extremities. This frequently leads to 
the suspicion that the hip is the seat of disease. In addition to the 
lameness there may be a tilting of the pelvis to one side, and sometimes 
quite a distinct lateral curvature of the spine. Eeferred pains are not 
so frequent nor so severe as when the upper part of the spine is affected ; 
they may be felt in the groin, in the loin, in the thigh, in the buttock, or 
in the hypogastrium. The gait and attitude are very characteristic: 
Throwing the shoulders well back, the patient walks stiffly, with short 
steps, holding the spine with the greatest care. He rises from the floor 
awkwardly and with difficulty. Deformity is not usually so early nor so 
marked as when the disease is dorsal, and often before it is visible there 
are symptoms due to the formation of psoas abscess — lameness, flexion 
of one thigh, and a tumor deep in the iliac fossa or at the upper and 
inner aspect of the thigh; in both locations it has often been mistaken 
for hernia. 

Physical Examination. — Whenever any of the above symptoms are 
present, the child should be stripped and submitted to a thorough ex- 
amination, the purpose of which should be to determine, first, the 
existence of any deformity; secondly, the mobility of the spine; thirdly, 
the presence of any secondary lesions, such as abscesses or paralysis. 
The mobility of the spine is best determined by studying the attitude, 
gait, and posture of the child, and the manner of stooping or rising 
from the floor. The gait has already been described with the symptoms 
of lumbar disease. As it has been aptly put, "the child walks with his 
legs, but not with his back/' In stooping, the same disinclination to 
bend or move the spine is seen. It is often impossible to induce the child 
to stoop at all, and when he does so, to pick up some object, there is 
acute flexion at the knee and hip, but as little bending of the spine as 
possible. In rising from the recumbent position the same thing is seen. 
The posture and attitude of the child will be modified by the position 
of the disease, and somewhat by the activity of the process at the time; 
however, by comparing the movements referred to with those of a 
healthy child, the great difference will at once be apparent. Jf the 
symptoms point to cervical disease, a digital exploration of the pharynx 



910 DISEASES OF THE BOXES AND JOINTS 

for deformity or abscess should be made, and the extremities should 
be examined for paralysis. If the disease is in the lumbar region, 
deep palpation of the iliac fossa should be made to discover a psoas 
abscess, and the passive movements of the thigh should be carefully 
tested to determine whether there is any resistance to extreme extension, 
this often being present before the psoas tumor. No matter how 
clearly the lameness may be at the hip, it should be remembered that 
this often results from disease of the lumbar spine. If the thigh is flexed 
and freely movable except in extension, the symptoms are probably the 
result of psoas irritation, for in hip- joint disease the other movements 
of the joint are also resisted. 

The deformity of Pott's disease is often spoken of as "angular" cur- 
vature of the spine. While this is a true description of the disease at 
an advanced stage, there is often in the early stage only a general curve. 
Later a slight knuckle is seen from the unnatural projection of a single 
spinous process. This deformity may increase and finally involve five or 
six vertebrae. It is usually greatest in the upper dorsal region. A slight 
prominence, which does not disappear on suspending the patient, is 
always suspicious. 

Tenderness upon pressure over the spinous processes and increased 
sensitiveness to heat and cold are rarely present. Pain may sometimes 
be produced by downward pressure upon the head or shoulders in the 
axis of the spine. This symptom is not necessary for diagnosis, and the 
attempt to elicit it is strongly condemned by Gibney, who has seen 
serious harm follow such a test. 

Course of the Disease. — Caries of the spine is a very chronic disease, 
its course being measured by months or years, but marked, as in all 
chronic diseases, by periods of remission and exacerbation. An exacer- 
bation may follow traumatism, and is often accompanied by the forma - 
lion of an abscess. After the disease has lasted from one to three years, 
the destructive inflammation usually ceases and repair begins, a cure 
being filially effected by a process of consolidation of the fragments 
of the diseased vertebrae, and the production of ankylosis. Eelapses are 
easily excited by traumatism, by improper treatment, or by discon- 
tinuing the use of mechanical supports before the disease is quite 
arrested. 

Abscesses. — The frequency with which abscesses occur depends some- 
what upon I he treatment. Townsend states that of 380 cases, abscess 
was j) resent in twenty per cent. They are rarely seen earlier than 

,lin c four months from the beginning of symptoms, and usually 

belong to the second year of the disease. They sometimes form with 
acute symptoms, but more frequently they appear as typical cold 
abscesses. 'Those connected with cervical disease are retropharyngeal or 



CARIES OF THE SPIXE Oil 

retroesophageal, or they may open externally, usually just above the 
clavicle, in front of the sternomastoid muscle. Those with disease of 
the lower cervical and upper dorsal vertebrae are apt to burrow along 
the spine, appearing in the lumbar region; rarely they may rupture 
into the esophagus or the pleural cavity. Those with disease of the 
lower dorsal or lumbar vertebrae may open just above the iliac crest 
posteriorly, or burrow anteriorly between the abdominal muscles, but 
the usual course is for them to follow the psoas muscle, appearing in 
the groin just above Poupart's ligament or at the upper and inner 
aspect of the thigh. 

Paralysis occurs in about one-half the cases in which the disease 
affects the lower cervical and upper dorsal vertebrae, but it is rare when 
the disease is below the middle dorsal region (see Compression Myelitis). 

Prognosis. — The actual mortality of Pott's disease is difficult to state, 
so many of the consequences of the disease being remote and not fully 
appreciated until adult life is reached. The general mortality from all 
causes is from ten to twenty per cent. The causes of death are exhaus- 
tion from prolonged suppuration, amyloid degeneration, myelitis, gen- 
eral tuberculosis, and tuberculous meningitis. Sudden death occasion- 
ally occurs from pressure upon the cord in the upper cervical region. 
or from the pressure effects of abscesses in the posterior pharynx or in 
the posterior mediastinum. 

The prognosis as to the amount of permanent deformity will depend 
upon the seat of the disease, the time at which treatment is begun, and 
upon the thoroughness with which it is carried out. The best results as 
to deformity are obtained when the disease is below the middle dorsal 
region. With improved methods of treatment begun early, a large 
number of these patients recover with an insignificant amount of de- 
formity, and some with none whatever. 

Diagnosis. — The spinal deformity resulting from Pott's disease may 
be confounded with rachitic kyphosis or with rotary lateral curvature. 
Rachitic curvatures are usually seen in children under eighteen months 
of age, a time when Pott's disease is rare ; there are other signs of rickets 
present, and instead of rigidity there is usually undue mobility of the 
spine. What is true of rickets may be said of all curvatures depending 
upon malnutrition. In young children, especially, the tuberculin test is 
of considerable assistance in diagnosis. 

Rotary lateral curvature is seen about puberty, rarely in young chil- 
dren except in connection with rickets. A slight lateral deviation of the 
spine, sometimes seen in the early stages of caries, may resemble a case 
of incipient rotary curvature. The latter is not attended by pain or 
rigidity, and is most frequent in young girls from eleven to fourteen 
years of age. 



912 DISEASES OF THE BONES AND JOINTS 

Other abscesses may be mistaken for those dependent upon vertebral 
caries. This difficulty is likely to exist in the cases attended by very 
little spinal deformity. These abscesses are most frequently in the iliac 
fossa or in the lumbar region, and may be due to perinephritis or ap- 
pendicitis. The latter are more acute than those depending upon bone 
disease and usually accompanied by fever. Tumors of the vertebrae or 
of the spinal. cord may give rise to symptoms almost identical with those 
resulting from compression myelitis due to Pott's disease. Both of 
these are rare (vide Tumors of the Cord). 

Treatment. — The treatment of Pott's disease is both general and 
local, and neither should be neglected. The constitutional treatment 
should be similar to that employed in other forms of tuberculosis. The 
local treatment belongs to the domain of orthopedic surgery. 

Articular Ostitis of the Hip — Hip- Joint Disease 

In early childhood this generally begins as a chronic ostitis in the 
head of the femur, starting near the epiphyseal line. Exceptionally, 
and oftener in older children, it begins in the acetabulum. The path- 
ological process, as well as the clinical history, is generally described as 
consisting of three stages. In the first stage — that of ostitis — the lesions 
are limited to the bone; in the second stage — that of arthritis — all the 
joint structures are involved, and in this stage suppuration' usually 
occurs; in the third stage there is breaking down and absorption of 
the head and sometimes of the neck of the femur, which, with destruc- 
tion of the ligaments, leads to marked displacement of the parts from 
muscular contraction. The disease may be arrested in the first or in 
the second stage, or it may continue through all three stages. 

Symptoms. — Clinically, the usual duration of the first stage is three 
or four months ; it may last only for a few weeks, it may extend over two 
or three years, and the disease may be arrested in this stage. The onset 
is usually very gradual, and the symptoms are often considered of trivial 
importance until they have continued for some weeks. Generally the 
first iliing noticed is slight lameness, due to stiffness of the joint. In 
the beginning this may be seen only in the morning, wearing off during 
ili" day. It may be accompanied by some tenderness about the hip and 
a disinclination to walk. A little later the child complains of pain, 
which is most frequently referred to the front of the knee or the inner 
aspecl of the thigh, but only in rare cases to the hip itself. This is slight 
at first, but gradually increases in frequency and severity, and soon there 
arc added the ''starting pains" at night, which are one of the most 
characteristic features of early hip disease. These pains are produced by 
a sudden spasm of the muscles during sleep. The child often cries out 



HIP-JOIXT DISEASE 



91; 



sharply without waking, sometimes wakes with a cry; this is often re- 
peated several times during the night. Soon restlessness and fretfulness 
during the clay are present. The lameness, which at first was slight and 
occasional, or noticed only in the morning, comes to be a constant symp- 
tom, and week by week increases in severity. The evolution of these 
symptoms may take only a few weeks, but sometimes they come and 
go in the most inexplicable manner during a 
period of several months, or even one to two 
years, before they are fully developed. 

Every child with a suspicious lameness, or 
with pains like those mentioned, should be 
stripped and submitted to a thorough exam- 
ination. The first points to be observed on 
inspection relate to the general contour of the 
hip ; every prominence and depression should 
be carefully noted. Then the attitude and 
gait should be studied; and finally all the 
functions of the joint should be carefully 
tested, and the limbs measured, to determine 
the existence of shortening or atrophy. At 
every step a comparison should be made with 
the sound limb. The contour of the hip is 
changed quite uniformly ; there is broadening 
and flattening of the whole gluteal region; 
the trochanter is unnaturally prominent; the 
gluteal fold is shortened, and often single in- 
stead of double. There is no characteristic 
position of the limb in this stage. There is 
atrophy of the thigh and often of the calf 
In Fig. 147 is shown the appearance of a typ- 
ical case in the full development of the first 
stage. In walking, the child favors the dis- 
eased side, throwing the weight as much as 
possible upon the sound limb; but all these 
symptoms are of much less importance for 
diagnosis than is an examination of the func- 
tions of the joint. 

For this purpose the child should be placed upon a table upon his 
back, and the various movements of the hip — abduction, adduction, 
flexion, extension, and rotation — should be executed, first with the sound 
limb and then with the suspected one, the two being carefully compared 
at every point to determine the degree of motion allowed. It is not 
necessary that force should be employed or pain inflicted. If the 




Fig. 147. — Hip- Joint Disease, 
at the End of the First 
Stage. Showing muscu- 
lar atrophy, prominence 
of the trochanter, flatten- 
ing of the gluteal region, 
and a single gluteal fold. 



914 DISEASES OF THE BONES AND JOINTS 

symptoms have existed for some weeks, there is generally a limitation 
of motion at the hip in all directions, but first usually in abduction, 
rotation, or extension. In more advanced cases, no motion whatever 
may be permitted at the joint, the pelvis tilting with the slightest 
movement of the femur. This fixation of the hip is due to tonic mus- 
cular spasm. Crowding the articular surfaces together, by pressure 
upon the heel or trochanter, produces pain, which is usually referred 
to the joint. This test should be carefully made, lest injury be inflicted. 
Examinations should not be made under ether, since in this way serious 
injury may be done unconsciously. 

Second Stage. — This has been called the stage of arthritis. Its 
existence may be assumed when the limb takes the position of marked 
permanent deformity, which is due at this period to muscular action, 
not to destructive bone changes. The transition from the first to the 
second stage is in most cases a gradual one, and the line between the 
two can not be sharply drawn; sometimes, however, it is rapid, and 
marked by a sharp exacerbation of all the symptoms. This may indicate 
a sudden perforation of the joint and the rapid development of sup- 
purative arthritis. Such is the usual result when an abscess which has 
been slowly forming in the bone opens into the joint; or acute joint 
inflammation may be lighted up without so evident a cause. Sometimes 
the pus reaches the surface below the capsular ligament, and the joint 
remains intact. An acute exacerbation is indicated by increased pain, 
excessive tenderness about the hip, often by inability to walk, or even 
to bear any weight upon the limb, and frequently by fever. The posi- 
tion assumed by the limb is now fairly characteristic. The foot is 
generally everted, the thigh slightly flexed and rotated outward, and 
the limb apparently lengthened. There may be infiltration anywhere 
about the hip, due to the formation of an abscess. The muscular 
spasm is so great that the joint is locked — no motion whatever being 
allowed. Abscesses may form at any point about the hip; they are 
especially frequent at the upper and outer aspect of the thigh, and may 
burrow long distances before reaching the surface. The duration of the 
second stage also is indefinite, but it usually lasts from a few months 
to a year, or the disease may be arrested in this stage. 

Third Stage. — There is now marked deformity, which is the result 
of muscular contraction after absorption of the head and sometimes the 
neck of the femur, and destruction of the ligaments. The position of 
the Limb is a very constant one, and resembles that present in dislocation 
upon 1 lie dorsum of the ilium. There is shortening of from one to four 
inches; the thigh is strongly flexed, adducted, and rotated inward, and 
the fool, is inverted; the trochanter lies against the outer surface of the 
ilium, and is above Nelaton's line. In this position the joint may be- 



HIP-JOIXT DISEASE 915 

come ankylosed. The displacement usually comes on gradually, but it is 
sometimes so sudden as to be mistaken for a true dislocation, although 
the latter is exceedingly rare in the course of hip disease. 

There is now marked atrophy of all the muscles of the limb, and the 
thigh may be two or three inches smaller than its fellow. No motion at 
all is usually allowed at the hip, but this is compensated for to some 
degree by the exaggerated mobility of the lumbar spine. The spinal 
curvature — lordosis — is very marked both upon standing and walking. 
The duration of this stage may be several years. From time to time 
exacerbations occur, often excited by falls, and accompanied by the 
formation of new abscesses. In protracted cases, all the soft parts about 
the hip may be seamed with cicatrices from old sinuses. After the dis- 
ease has gone on to the third stage, cure can take place only by anky- 
losis. 

Diagnosis. — The important point in the early diagnosis of ostitis of 
the hip, is the gradual evolution of the symptoms, the most characteristic 
of which are lameness, "starting pains" at night, and impairment of 
all the functions of the joint. Mistakes in diagnosis most frequently 
arise from a failure to obtain a careful history, and from relying too 
much upon the symptoms of lameness and deformity. The essentially 
chronic character of the disease should constantly be borne in mind. 
In the vast majority of cases, with a careful history and a thorough 
examination, there can be but little doubt as to the diagnosis except 
at the very outset. The proportion of obscure and irregular cases to 
those following the regular course is small. 

In the early stage, hip-joint disease may be confounded with a strain 
of the joint, with muscular rheumatism, poliomyelitis, periostitis of the 
shaft of the femur, phlegmonous inflammation in the neighborhood of 
the joint, or with caries of the lumbar spine. In the second stage there 
is even less difficulty in diagnosis, although abscesses resulting from 
perinephritis or appendicitis have been mistaken for those arising from 
hip disease. In the third stage, a mistake is almost impossible. 

Prognosis. — This is to be considered both with reference to life and 
limb. The records of the Hospital for Euptured and Crippled show the 
mortality of hospital patients with hip disease to be nearly twenty-five 
per cent. This includes deaths directly or indirectly traceable to the 
disease. The causes are nearly the same as in caries of the spine — 
exhaustion from prolonged suppuration, amyloid degeneration, and gen- 
eral tuberculosis or tuberculous meningitis. 

Under the most favorable conditions, the disease may be arrested in 
the first stage, and recovery occur without lameness or any noticeable 
impairment of the joint functions. This result, however, is not often 
obtained, because the disease is usually well advanced before it is recog- 



916 DISEASES OF THE BONES AND JOINTS 

nized, or because of the difficulty in the way of carrying out all the 
details of treatment in the best possible manner. If the disease has 
advanced to the second stage and suppuration has occurred, there always 
results some impairment of the joint functions ; usually there are decided 
lameness and marked muscular atrophy, but very little shortening or 
deformity, provided the limb has been kept in the proper position. If 
the disease has advanced to the third stage, there are always marked 
shortening, deformity, and lameness. 

Treatment, — The indications for constitutional treatment are the 
same as in caries of the spine. The purpose of local treatment is to 
secure constant and complete rest for the diseased parts, and to prevent 
deformity. It should be in the hands of an orthopedic surgeon. 

Articular Ostitis of the Knee — Knee-Joint Disease — White Swelling 

Ostitis of the knee usually begins in one of the condyles of the femur ; 
the inner much oftener than the outer one; less frequently it begins in 
the head of the tibia. The pathological process is very much like that 
at the hip. There is in the first stage a central ostitis accompanied by 
infiltration and expansion of the part of the bone affected. The disease 
may remain limited to the bone, the inflammatory products becoming 
encapsulated, or softening and breaking down may occur, with the for- 
mation of an abscess. Gradually the process extends outward, and the 
periosteum and the soft parts are involved. The disease may invade the 
joint itself in a destructive inflammation, or pus may escape externally 
without seriously involving the joint structures. The degree to which 
the joint is involved varies much in different cases; there may be only 
a simple synovitis, a suppurative arthritis, or a destruction of the car- 
tilages and articular ends of the bones, synovial membrane, and liga- 
ments, so that in the advanced stage all traces of a joint structure 
are lost. 

If the process remains limited to the bone, recovery may take place 
with very little impairment of the joint functions. If suppuration 
in the joint has taken place, there will be more or less stiffness and 
fibrous or bony ankylosis. When there is destruction of the ligaments 
and articular ends of the bones, the limb assumes a characteristic posi- 
tion — the joint is flexed, the tibia is displaced backward and rotated 
outward, and there is marked over-riding of the femur. Bony ankylosis 
in this position is often seen. 

Symptoms. — The earliest symptoms of disease at the knee are usually 
a slight stiffness of the joint, with a disposition to flexion and slight 
lameness. At first these symptoms are noticed only occasionally; finally 
they become constant and there is pain, which is usually referred to the 



KNEE-JOINT DISEASE 917 

knee. In some eases there are "starting pains" at night, although these 
are less constant and less severe than in hip disease. Swelling is noticed 
earl)-, as the diseased parts are superficial. At first this is chiefly of the 
hone itself; the condyle, usually the inner one, is enlarged and elon- 
gated, often to a marked degree, before there is any infiltration of the 
soft parts. Later there is a general fusiform swelling, involving the 
entire joint and effacing all the normal outlines. Some tenderness upon 
pressure over the bone affected is present quite early, and there may be 
atrophy of the muscles of the thigh and calf. The knee is flexed and 
slightly rotated outward, the position which secures the most complete 
relaxation of the joint structures. In some cases there is seen the char- 
acteristic swelling due to distention of the synovial membrane. Ab- 
scesses may form anywhere about the joint; very frequently they burrow 
beneath the tendon of the quadriceps extensor as far as the middle of the 
thigh. Gradually the deformity increases until the leg may be flexed at 
a right angle, and rotated outward over an arc of twenty or thirty 
degrees. 

The course of the disease resembles that of ostitis of the hip and the 
spine. During periods of remission pain and tenderness often subside 
for several months so completely as to lead to the supposition that the 
disease has been arrested. An exacerbation is often excited by a fall or 
a strain of the joint, or it may follow an attack of acute illness. The 
disease may then progress rapidly and abscess after abscess form, with 
extensive destruction of all the joint structures and the production of 
permanent deformity. 

Prognosis. — The danger to life is considerably less than in disease of 
the hip or spine. Death, however, results from the same causes — exhaus- 
tion, amyloid degeneration, and general tuberculosis or tuberculous 
meningitis. 

With an early .diagnosis and proper treatment the disease may, in a 
considerable proportion of cases, remain limited to the bone, and the 
resulting lameness and deformity be very slight ; but otherwise a certain 
amount of lameness results from the stiffness of the joint. This may be 
due either to fibrous thickening or to bony ankylosis. Xearly all patients 
are able to walk without crutches, and if proper treatment has been 
carried out there is neither marked shortening nor deformity, although 
there is always great muscular atrophy. 

Diagnosis. — The important symptoms for diagnosis are the gradual 
onset, the early swelling which is due to enlargement of the bone, and 
the constant lameness and deformity. The disease may be confounded 
with rheumatism, with synovitis, and even with scurvy. In all these 
cases the resemblance exists only during the period of exacerbation. A 
careful history, however, will usually make the diagnosis clear. 



918 Diseases of the bones and joints 

Treatment. — The general treatment is the same as in other forms of 
joint disease. The indications for local treatment are the same as in 
hip disease. 

Tuberculous Osteomyelitis 

This disease is rarely seen except in the short tubular bones, most 
frequently those of the hand and fingers. From this fact it is often 
called scrofulous or tuberculous dactylitis. It is described by many 
writers under the name of spina ventosa. Unger gives the following 
figures showing the frequency with which the different bones were af- 
fected: fingers in 43, toes in 3, metacarpus in 41, metatarsus in 14, 
radius in 2, ulna in 2, tibia in 3, jaw in 3. The first phalanx of the index 
finger is the bone which is most frequently the seat of disease. In the 
majority of cases the process is confined to a single bone, although it is 
not rare to see five or six affected. In such cases the disease is seldom 
symmetrical. The process is a chronic inflammation, beginning in the 
center of the bone with the deposit of tuberculous material. The swell- 
ing which follows causes an expansion of the bone and thinning of the 
shaft, until a mere shell may remain. The later changes are inflamma- 
tion of the periosteum and the soft parts, the formation of abscesses and 
sinuses, necrosis, the exfoliation of sequestra, etc. The entire disease 
lasts from one to three years, and causes in most cases marked deformity. 

Tuberculous dactylitis is essentially a disease of early childhood, be- 
ing seen most frequently during the second and third years. The 
disease frequently appears to be the only tuberculous lesion in the body, 
but tuberculosis of other parts, especially other bones, may be associated. 

Symptoms. — The disease usually begins as a painless enlargement of 
one of the phalanges, most frequently the first one of the index finger. 
It may be two or three months before it is of sufficient size to attract 
much attention. Exceptionally the inflammation is a more active one, 
and is accompanied by both pain and tenderness. The swelling is quite 
characteristic; it is smooth, hard, uniform, and generally spindle- 
shaped, involving the entire phalanx of the affected finger. The appear- 
ance of a severe typical case is shown in Fig. 148. Later there is 
discoloration of the skin, and usually there is suppuration. The abscess 
generally opens at the side of the finger, and a curdy pus is evacuated. 
[f the opening is enlarged by an incision there is found a cavity partly 
filled with caseous matter, and dead bone is felt, and perhaps a. loose 
sequestrum. The cavity is surrounded by a thin shell of new bone, 
which is formed From the periosteum. If no operation is done the dis- 
charge continues for weeks or months, other abscesses often form, and 
finally several small sequestra are exfoliated — sometimes a single large 
one— which is the shell of the diseased phalanx almost entire. 



TUBERCULOUS OSTEOMYELITIS 010 

In some cases the disease is arrested before necrosis occurs, but in the 
majority this is not so. After the wounds have all healed the finger 
remains shortened, deformed, and often useless. In some cases the dis- 
organization is so extensive that amputation is necessary. 

Diagnosis. — The recognition of dactylitis is usually easy, but as 
symptoms almost identical may be seen in a syphilitic inflammation, it 
is often difficult to tell with which of the two forms one has to deal. 
The tuberculous form is much more frequent and is usually seen in 
children over two years of age; it may occur in a patient with tuber- 
culous antecedents, or it may be associated with other tuberculous 




Fig. 148. — Tuberculous Dactylitis. 

lesions. Syphilitic dactylitis is distinguished by the fact that it is more 
often seen in young infants, that the lesion is more frequently multiple, 
that it is often symmetrical, and that other manifestations of syphilis 
are generally present. The Wassermann and the tuberculin tests give 
definite information in nearly all cases. 

Treatment. — Painting with iodin and like measures are useless. The 
diseased part should be kept at rest — if a finger, by the application 
of a splint. Every means should be taken to build up the patient's gen- 
eral health, as this is the most effective way to influence the local process. 
The general verdict of surgeons is against early excision as a means of 
arresting the disease. Abscesses should be opened early and freely, all 
diseased bone removed, the finger kept in proper position, and the wound 
treated according to general surgical principles. Under almost any 
treatment the disease is a protracted one, and rarely lasts less than a 
year. 



920 DISEASES OF THE SKIN 

CHAPTER V 
DISEASES OF THE SKIN 

The skin at birth is covered with a whitish sebaceous secretion, the 
vernix caseosa. The skin itself is of a deep-purplish color, which 
changes to a bright red over the face and trunk in a few minutes, with 
the establishment of normal respiration, and in a few hours the whole 
bod) T has the same tint. This excessive redness slowly fades during the 
first month, at the end of which time the skin has assumed the pale pink 
of infancy. On the third or fourth day there may be seen the first signs 
of physiological icterus ; this generally disappears by the end of the second 
week. 

The epidermis which is present at birth soon loosens and is thrown 
off. This normal desquamation usually begins upon the fourth or fifth 
day, and is completed in ten days or two weeks. If the skin is fre- 
quently oiled and properly bathed, desquamation is scarcely noticeable 
unless a close examination is made. In some infants, especially those 
who are delicate and cachectic, it is very much more marked. 

Perspiration is rarely present before the end of the fourth month, 
and is then seen only upon the forehead. In healthy infants it is 
scarcely noticeable during the first year. Copious perspiration is most 
frequently a symptom of rickets; less marked perspiration may occur 
with any general weakness or during acute illness. 



CONGENITAL ICHTHYOSIS 

Congenital, or more properly fetal, ichthyosis in its severe form is 
a rare disease, characterized by the formation, usually all over the body, 
of a thick, horny epidermis resembling parchment. This is divided by 
fissures or shallow furrows into irregular patches; sometimes these are 
two or three inches wide, at others as small as a pins head. In its 
milder form it is not uncommon. The disease begins in the early 
months of fetal life, and is an abnormality in the development of the 
skin, there being an excessive proliferation of the layers of the epi- 
dermis. 

Symptoms. — In the gravest form of the disease the child often lives 
bul a few hours, and rarely more than a week. The openings of the 
nostrils and the cars may be occluded by the excessive production of 
epithelial cells. The eves are in a condition of ectropion, and there are 
often deformities of the mouth and other orifices due to the contractions 



MILIARIA 



921 



of the skin. The nails and hair are usually imperfectly developed. The 
body seems encased in a hard, horny covering, and looks as if it had been 
varnished or covered with collodion. The skin cracks or splits and the 
edges curl up 3 an appearance which has been aptly compared to the skin 
of a boiled potato. 

In the milder form, the duration of life is indefinite, depending upon 
the degree of development of the disease; but even in such cases there 
may be seen the deformities at 
the orifices of the body, and 
there may also be a continued 
exfoliation of the epidermis in 
large irregular patches. After 
ihiii has separated, the skin be- 
neath appears red and moist, 
but gradually becomes dry, 
hard, and shining, slowly con- 
tracting until it splits in vari- 
ous directions. 

The outlook is unfavorable 
in all cases; in most of the se- 
vere forms death occurs in in- 
fancy, but in some of the mild- 
er ones, life may be prolonged 
indefinitely. The "alligator 
boy" of the "Dime Museum" is 
an example of this class. 

Treatment. — The indica- 
tions are to keep the skin moist 
and soft by the use of oils, con- 
tinuous baths, etc., and to pre- 
vent infection by perfect clean- 
liness. Although a certain 

amount of improvement usually follows these measures, a cure is not to 
be expected. 




Fig. 



149. — Congenital Icthyosis, Six Weeks 
Old. 



MILIARIA 



The term miliaria is applied to an obstruction of the sweat glands, 
which may occur either with or without inflammation. The non-inflam- 
matory form is known as sudamina the inflammatory forms as miliaria 
rubra, wAliaria vesiculosa and miliaria papulosa. 

Sudamina. — In this form there is no inflammation. The sweat ducts, 
according to Crocker, are blocked by an accumulation of epithelial cells 



922 DISEASES OF THE SKIN 

while no perspiration is going on ; and when the process is restored the 
fluid, being unable to escape, accumulates in the form of tiny vesicles. 
These appear like small pearly bodies very closely set, and disappear in 
the course of a few days by absorption. Fresh crops may appear from 
time to time. Sudamina may be seen in any of the continued fevers or 
exhausting diseases. It requires no treatment. 

Miliaria Rubra. — This condition, also known as red gum, strophulus, 
etc., is a sweat rash, usually seen in young infants as the result of ex- 
cessive clothing. It is most frequently observed upon the cheeks and 
neck, often upon the side of the face upon which the infant sleeps, or the 
side held against the mother's body while nursing, if this is done upon 
only one breast. The eruption consists of scattered red papules, some- 
times with tiny vesicles. Miliaria rubra is an inflammation about the 
sweat glands, the result of which is a retention of their secretion. There 
is generally little or no itching. The treatment consists in the removal 
of the cause, and the application of some absorbent powder, such as 
boric acid and starch. 

Miliaria Papulosa (Lichen Tropicus, Prickly Heat, etc.). — This is 
the most common and most important variety of miliaria. There is in 
this disease an obstruction of the sweat glands by inflammatory products. 
The lesion consists in the formation of bright-red papules, which are 
very closely set, the summits of some of them being surmounted by tiny 
vesicles, and here and there in severe cases even small pustules may be 
seen. If not interfered with by scratching, the vesicles dry up without 
rupture, and are followed by a slight desquamation. Where there is much 
scratching, an eczematous condition may result. Miliaria papulosa comes 
out with great rapidity, especially upon the neck, forehead, back, and 
chest. It is accompanied by an almost intolerable itching and stinging 
sensation. Over other parts of the body profuse perspiration occurs. 
The disease is produced by very hot weather and excessive clothing. 
Although the duration of a single attack is but two or three days, in 
susceptible patients it may keep recurring for weeks, being exceedingly 
intractable. Where there is much scratching, the resulting eczema is 
very troublesome. It is not infrequently followed by furunculosis. 

The diagnosis of:' miliaria rubra and miliaria papulosa is usually easy. 
They are distinguished from eczema by the suddenness w r ith w^hich they 
appear, by the associated sweating of other parts of the body, by the 
transitory character of the eruption, and by the fact that the rash never 
occurs in circumscribed patches. 

Prickly heat is to be prevented by light clothing, frequent bathing, 
and (be plentiful use of a good toilet powder, such as boric acid and 
Btarch. The skin should be protected against the irritation of flannel 
undergarments by the interposition of silk or linen. When the inflam- 



ECZEMA 923 



mation is at its height, relief is obtained by the application of a calamin 
and zinc lotion, or by a dilute solution of the acetate of lead; carbolic 
acid may be added to either, when the itching is intense. In some cases 
bland powders are preferable to lotions. 



SEBORRHEA 

Seborrhea is considered by dermatologists generally, as a functional 
disease of the sebaceous glands ; although Unna regards all such cases as 
parasitic in origin and inflammatory, and classes them as seborrheic 
eczema. The disease may affect almost any part of the body, and chil- 
dren of any age, but the most frequent form is that which is seen upon 
the scalp in young infants. This is the most important variety, and 
the only one which will be here considered. 

Seborrhea of the scalp is characterized by the formation upon the 
vertex, of dirty-yellow crusts, which are soft, greasy, and friable. They 
are composed of epithelial cells, fat-globules, and granular masses, to 
which is always added dirt. In neglected cases the hairy scalp is nearly 
covered by a dense crust, which may be as thick as heavy pasteboard. 
If the crusts are removed the underlying scalp may be found perfectly 
healthy, but more frequently, in cases of long standing, it is eczematous. 
The eczema is set up by the decomposition of the exudation, or by the 
efforts to remove the crusts by such means as the fine-toothed comb, com- 
monly employed in domestic practice. There is little tendency to spon- 
taneous improvement or recovery, and the condition often lasts for 
months. Every seborrhea should be treated, for when neglected it fur- 
nishes a favorable soil for the development of eczema. 

Only local treatment is required. The crusts are first to be softened 
with oil, and then removed by washing thoroughly with warm water 
and soap, after which an ointment of resorcin, 2-per-cent strength, or of 
sulphur, 10-per-cent strength, should be applied. The oil and soap and 
water are repeated every few days, or as often as the crusts form. In 
the meantime the scalp is kept covered with the ointment. 



ECZEMA 

Eczema is the most frequent and altogether the most important dis- 
ease of the skin in early life. The scope of the present work permits 
only a discussion of such features and varieties as are peculiar to in- 
fants and young children. The eczema of older children does not differ 
in any essential points from that of adults. 



924 DISEASES OF THE SKIN 

Etiology. — The conditions in infancy which predispose to eczema 
are, first, that the skin is extremely delicate, and hence more easily 
affected by external irritants and microorganisms; secondly, its more 
intense glandular activity. While all children are susceptible, there are 
certain ones in whom the susceptibility is very marked, and in them the 
slightest amount of external irritation, or the most trivial disturbance 
of digestion may produce a severe eruption. Eczema is one of the chief 
manifestations of the exudative diathesis (Czerny). It is especially 
prevalent in some families and is not infrequently inherited with the 
other evidences of the diathesis. Eczema is common in fat, healthy-look- 
ing infants, both in those who are nursing and in those who are arti- 
ficially fed. It rarely occurs in poorly nourished children. Children 
with eczema are not infrequently subjects of asthma in later life. Ec- 
zema may apparently be initiated and is certainly aggravated by over- 
feeding, whether it be with breast milk or artificial food. The food ele- 
ment which seems to be particularly to blame is the fat, but farinaceous 
food in excess has also a bad effect. Schloss and Blackfan have shown 
that there is a susceptibility to animal protein on the part of most pa- 
tients with eczema, as shown by cutaneous tests with various proteins. 
Most of the patients are susceptible to egg white and many to cow's 
milk. A few are susceptible to woman's milk. Some children even with 
severe eczema are insusceptible. The exact meaning of this susceptibility 
is not clear. 

The exciting causes of eczema may be external or internal. Of the 
former the most important are heat, cold dry air, and winds — as in the 
familiar chapping of the face — the use of "hard" water or of strong soaps 
in bathing. The disease may be due to the irritation of clothing, to 
want of cleanliness, or to irritating discharges from mucous surfaces, as 
in the eczema of the upper lip, thighs, or buttocks. It accompanies most 
of the parasitic skin diseases, particularly pediculosis, scabies and ring, 
worm. 

What part is played by microorganisms in the etiology of eczema 
has not yet been fully determined. As a primary factor they do not 
seem to be of the first importance. Secondary infection, however, occurs 
in most cases, and this is important in keeping up the disease. 

Simple Chronic Eczema — Eczema Rubrum. — This is the most fre- 
quent form of eczema occurring in infants and young children, and is 
usually seen upon the face. It affects by preference the cheeks, forehead, 
and scalp, not infrequently the ears and neck, and may occur upon any 
pari of the body. Upon the trunk and extremities the eruption is usually 
in patches, hiil in rare cases may cover nearly the entire body. The dis- 
ease generally begins upon the cheeks with the formation of small red 
papules: later these coalesce, and there is a moist, red surface exuding 



ECZEMA 925 

serum. The secretion dries and forms thick, gummy crusts, which 
may be so hard as to form a mask for the face. From the scratching 
caused by the almost intolerable itching, the surface bleeds freely, and 
the dried blood gives to the crusts a dirty-brown color and adds to the 
distressing appearance. The skin is often much swollen. After the 
removal of the crusts there is seen, in acute cases, a red, inflamed, gran- 
ular surface, moist and bleeding readily. When the process is less 
active, there is redness, thickening, induration, and scaliness of the 
skin, and marked itching. In the same case these stages may alter- 
nate, exacerbations occurring whenever the exciting cause is partic- 
ularly active. From the cheeks the disease spreads to the forehead, 
ears, and scalp, and here similar lesions are seen. Upon the trunk and 
extremities thick crusts rarely form, but the skin is red, thickened, and 
scaly. The parts most often affected are the forearms, legs, abdomen, 
and back; occasionally the eruption is general. Eczema of the occipital 
region of the scalp is usually due to pediculosis. 

Swelling of the lymph nodes in the neighborhood of the eruption 
is a constant feature of eczema of the face and scalp; these may reach 
the size of a chestnut or walnut, and occasionally they may suppurate. 
Intense itching is a characteristic feature of all cases of eczema of the 
face or scalp. 

While most children with eczema are well nourished in the begin- 
ning, and some remain so during a prolonged attack, the general health 
of many is undermined. The itching and discomfort cause constant 
irritability, loss of sleep, and other nervous symptoms which sometimes 
seriously impair the child's nutrition. 

The effects of very extensive eczema resemble in some particulars 
those of burns of the second degree. There may be fever, delirium, 
other nervous symptoms and even a fatal termination. We have seen 
several cases with a generalized eczema in which there developed, with- 
out evident cause, exceedingly high temperature, in two cases reaching 
109° F., accompanied by symptoms of a most profound intoxication. 
Most of the infants with such symptoms die, but one child recovered in 
whom the temperature mentioned was reached. No satisfactory explan- 
ation of these severe intoxications has yet been offered. 

There are some patients in whom an alternation of eczema and at- 
tacks of bronchitis with asthma may occur. During the eczema, the 
pulmonary symptoms are entirely wanting; but when the eczema is re- 
lieved the pulmonary symptoms rapidly develop. In a few patients an 
alternation of eczema and diarrhea is observed. 

Patients with eczema are exceedingly prone to develop attacks of 
diarrhea and this condition nearly always brings about a marked im- 
provement in the skin, though the diarrhea is often difficult to control. 
31 



926 DISEASES OF THE SKIN 

Eczema of the face is very chronic, easily improved, but cured only 
with great difficulty. There is a strong tendency to relapse, brought on 
by neglect of local treatment, by any digestive disturbances, or by over- 
feed Lag. 

The predisposition to eczema often ceases with the second year; those 
who have suffered from it almost constantly during infancy may be free 
from it during the remainder of childhood. This is in part to be ex- 
plained by the loss of fat in consequence of more active exercise and a 
diet which is more largely nitrogenous. When the disease continues 
through the third and fourth years, the associated infantile condition, 
obesity, is not infrequently present. 

Pustular Eczema of the Scalp. — This condition, often called "simple 
impetigo," is less frequently seen in infants than in children from two 
to five years old. There are usually present from half a dozen to fifty 
greenish-yellow crusts matting the hair, usually discrete, but sometimes 
coalescing to form a mask over half the scalp. There is very little itch- 
ing, in some cases none at all. The lymph glands are invariably en- 
larged. This form of eczema is due to infection with pyogenic organ- 
isms. The children constantly re-infect themselves, and in this way the 
disease may be prolonged indefinitely. It is possible, too, that infection 
may spread to other children. 

Intertrigo. — This term is rather indiscriminately applied to any 
eruption which develops upon two moist surfaces, which are in contact. 
It is often regarded as a form of eczema. There may be a simple 
erythema or an eczema resulting from traumatism or the decomposition 
of secretions. Intertrigo is seen in the folds of the groin, between the 
scrotum and the thighs, between the buttocks, about the anus, in the 
axillae, in the neck, or behind the ears. Its essential causes are moisture, 
friction, want of cleanliness, and sometimes infection. The disease is 
generally seen in its worst form about the thighs, genitals, and buttocks; 
it sometimes covers the sacrum and extends down to the middle of the 
thighs. There is an intense uniform redness, and in some cases the epi- 
dermis is denuded over large areas, and the surface is moist. There is 
no thick crusting and little or no itching. Intertrigo is usually easy to 
control except in very poorly nourished or marantic children, among 
whom il is especially frequent. 

Diagnosis of Eczema. — This is usually quite an easy matter. In the 
majority of eases, the disease affects the face or the scalp, and its appear- 
ances are typical. Eczema of the body or extremities may be confounded 
with scabies or syphilis, and occasionally with other forms of skin dis- 
ease. Scabies resembles eczema in its intense itching and multiform 
lesions; bid in the former, one may often find evidences of its presence 
in oilier members of the family; the parts most frequently affected are 



ECZEMA 927 

the flexures of the wrists, the elbows, the skin between the fingers, the 
margins of the axillae, the lower part of the abdomen and back, and, in 
boys, the penis; and by careful examination with a lens some of the 
characteristic burrows are certain to be discovered. 

Syphilis is likely to be confounded with papular eczema of the but- 
tocks. The latter affects the parts near the anus, and the irritation may 
lead to the development of spots closely resembling mucous patches. The 
local appearances may at times be indistinguishable from syphilis, and 
the diagnosis is to be made only by the other symptoms present. In 
syphilis the characteristic eruption is seen usually upon the face, hands, 
legs, and sometimes the palms and soles; there is no itching and very 
little evidence of inflammation; the eruption is copper-colored, and oc- 
curs as small circumscribed spots; there are usually present other symp- 
toms, such as the coryza, the syphilitic cachexia, and enlargement of the 
spleen. 

The diagnosis from pediculosis and ring-worm of the scalp, rarely 
presents any difficulties. 

Prognosis. — All cases of chronic eczema are tedious. There is only a 
slight tendency to spontaneous improvement, and very little to spontane- 
ous recovery during early infancy. About the end of the first year the 
disease disappears in many children; some relapse after this time, but 
others are never again troubled with eczema. In a severe case of gen- 
eral eczema the possibility of the development of severe toxic symptoms 
should not be forgotten. In any given case of eczema, the prognosis 
depends upon the duration of the disease, its severity, and very much 
upon the cooperation of the mother or nurse. The results obtained de- 
pend not only upon the particular line of treatment adopted, but upon 
how well it is carried out. Usually it must be continued for several 
months. Intertrigo is in most cases easily cured, unless the patient is 
suffering from extreme malnutrition. 

Treatment. — A judicious combination of general and local measures 
is necessary for the best results. Unless disturbances of nutrition can 
be removed, local treatment will give only temporary relief. External 
causes also must be investigated. 

A thorough investigation into the food is necessary, not only as to 
its character, but as to quantity and preparation, the manner and fre- 
quency of feeding, etc. If the patient is a nursing infant, very fat and 
well nourished, the amount of food should be reduced by lengthening 
the interval between feedings and shortening the time which the child 
is allowed to remain at the breast at one nursing. Plain water, or 
better, some alkaline water, should be given freely between the nursings. 
In children fed upon cow's milk the quantity may be too great, or the 
trouble may be with the sugar, but more frequently with the fat. This 



928 DISEASES OF THE SKIN 

should first be reduced and if no improvement occurs the sugar should 
also be diminished. 

During the latter part of the first and the entire second year, the 
usual error is that of overfeeding, with in some cases an excessive use 
of solid food, very often with too much milk. The diet should then be 
much reduced, and the amount of solid food restricted. The diet 
which suits most children best is one composed of a moderate amount of 
milk, beef juice, broth, cooked fruit and green vegetables; eggs and meat 
must be used with caution. The cereals — rice, wheat or barley — may be 
added, in small amounts at first. Any form of indigestion which exists 
is to be managed according to the special indications in each case. When 
there is a susceptibility to proteins, as shown by cutaneous tests, a reduc- 
tion or for the time a complete removal from the diet of the protein 
causing the reaction should be made with children over one year old. 
In older patients the results are sometimes very striking. 

The diet of older children needs to be watched no less closely than 
that of infants. The general rules laid down elsewhere for feeding after 
the second year should be observed. 

Elimination by the kidneys should be stimulated by the very free use 
of water, to which may be added an alkaline diuretic — the citrate or ace- 
tate of potassium, from ten to twenty grains daily. 

Attention to the condition of the bowels is of the greatest importance. 
To overcome the tendency to constipation is in many cases to cure the 
eczema. Suggestions under this head will be found in the chapter on 
Chronic Constipation. The bowels must not only be opened, they must 
be kept open by the daily use, if necessary, of some of the milder laxa- 
tives, such as magnesia, phosphate of sodium, rhubarb, or cascara. 

When the disease occurs in flabby, anemic, or poorly-nourished chil- 
dren, iron, arsenic and bitter tonics are required, but rarely cod-liver 
oil. In other words, the child's general condition should be treated just 
as if no eczema existed. 

The general management of cases is important. The skin must be 
carefully protected by an ointment whenever the child is in the open 
air; if the weather is very cold, or there, are high winds, children with 
active eczema should not go out, but be aired indoors. Never should an 
eczematous surface be washed with plain water, and much less with 
casl ile soap and water. When washing is necessary, it may be done with 
bran water, milk and water, or starch and water, to which borax (a tea- 
spoonful to the quart) may be added. The clothing should not be so 
excessive as to keep the child constantly in a perspiration. Napkins 
should nol be washed in strong soda solutions, nor, in ease of eczema of 
I be bullocks, should they ever be used a second time after being simply 
dried. 



ECZEMA 929 

Iii eczema of the face it is absolutely necessary to prevent the child 
from scratching the parts. The use of a mask is not always sufficient, 
nor the wearing of mittens; nor is the local application of anti-pruritic 
lotions or ointments altogether successful. In severe cases mechanical 
restraint is absolutely indispensable. The most satisfactory method is 
to surround the arms at the elbows by pasteboard splints, and hold them 
in place by bandages. This allows free use of the hands, but makes it 
impossible for the child to reach the face. 

Local Treatment. — Local treatment is always necessary, for not only 
are the causes sometimes entirely external, but the condition may persist 
after the original internal cause has. been removed. There are several 
indications to be met by local treatment at different stages in the disease : 
(1) To remove crusts and other inflammatory products; (2) to allay 
congestion and acute inflammation; (3) to relieve itching; (4) to pro- 
tect the delicate new skin which is forming; (5) to prevent infection; 
(6) to stimulate the skin in the chronic stages of the disease. 

Preparatory to the use of any application, the scales, crusts, and other 
products of inflammation must be softened and removed in order that 
the diseased surface may be reached. In most cases it is sufficient to 
soften the crusts by the use of olive oil for twelve or twenty-four hours, 
and then remove them by soap and warm water. If the crusts are very 
hard and thick, they can be softened by a poultice. During the stage of 
acute inflammation only sedative applications should be used, such as a 
lotion of zinc and calamin. 1 A piece of muslin should be dipped in the 
solution, and applied to the affected part, being kept in place by a ban- 
dage or the skin may be frequently wetted with the lotion which is al- 
lowed to dry on. If there is much itching, one per cent of carbolic acid 
may be added. 

Another plan of treatment, where there is much secretion, is to keep 
the surface covered with equal parts of boric acid and starch or talcum 
powder. An application which is often successful in allaying the in- 
tense burning and itching is black wash. This is applied several times 
a day in full strength or diluted and allowed to dry on, after which a 
protective ointment is used. 

A soothing application in general eczema is one composed of equal 
parts of lime-water and sweet-almond oil ; sometimes this may be advan- 
tageously followed by smearing the body with a thick starch paste and 
allowing it to dry on. 

1 I£ Pulv. calaminae preparatae 3ij 

Zinci oxidi 3ss. 

Glycerinae Si 

Liquor calcis 5i j 

Aquae rosao Sviij 



930 DISEASES OF THE SKIN 

As a simple protective ointment, one containing starch, zinc oxid, or 
bismuth, either alone or in combination, may be used. An excellent 
formula is zinc oxid ointment with two per cent of salicylic acid. 

Later, when the inflammation is less acute and the itching severe. 
tar in the strength of ten to twenty per cent may be substituted for the 
salicylic acid. 

All ointments used should be spread upon muslin, and kept in close 
contact with the inflamed part by means of a bandage or mask. Little 
or nothing is accomplished by simply rubbing the ointment upon the 
affected part. An ointment containing five or ten per cent of calomel 
is often the best application for an eczema which is not too extensive. 

The methods of treatment above mentioned are especially applicable 
to eczema of the face and scalp. For pustular eczema of the scalp the 
best application is the white precipitate ointment, which should be com- 
bined with three or four parts of vaseline. This is excellent also for 
small eczematous patches upon the body, but it is not to be, used over a 
large surface. 

In intertrigo, the treatment should have reference to the pathologi- 
cal condition which is present. Cases of simple erythema usually yield 
promptly to cleanliness and the free use of absorbent antiseptic powders, 
such as boric acid and starch in equal parts, or calomel two per cent may 
be used with talcum. If there is an acute dermatitis, the calamin and 
zinc lotion may be used, and later some protecting ointment. When in- 
fection has been added, lotions of resorcin or ichthyol, one-half of one 
per cent strength, should first be applied, and the skin then covered with 
one of the powders mentioned; both are to be repeated as often as the 
parts are wet by urine or soiled by feces. It is important in all cases 
that the diseased surfaces should be kept separated, which is best done 
by boric acid and starch. All napkins should be immediately removed 
when soiled. 

Tn cases of chronic eczema, where the skin remains thickened, red, 
scaly, and itching, stimulating applications are to be used, such as the 
tincture of green soap or stronger preparations of tar. 



FURUNCULOSIS 

A furuncle, or boil, is a circumscribed inflammation of the subcuta- 
neous cellular tissue, usually beginning in a hair follicle, and usually 
ending in suppuration. When severe, it may result in necrosis of the 
follicle, which tonus (he "core/* or the necrotic process may extend to 
the surrounding 1 issues for a variable distance. The ordinary boil need 
not be described, as it presents nothing peculiar in early life. The con- 



FURUNCULOSIS 931 

dition, however, which is characteristic of young children is the forma- 
tion of small ones in great numbers. It is to this more especially that 
the term furunculosis is applied. The principal location of these small 
abscesses is, in nearly all cases, the scalp, face, and shoulders, although 
they may be found upon any part of the body. They are sometimes 
numbered by hundreds, and appear in crops for a period of several 
months. In size, they usually vary from a pea to an almond, and they 
rarely contain a core. Infants are much more often the subjects of this 
disease than are those who have passed the second year. In the great 
majority of cases furunculosis is not serious, yet, occurring, as it often 
does, in infants who are already suffering from extreme malnutrition, 
whose tissues possess but little resistance, the process may develop into 
a condition which may prove fatal. 

Furunculosis may be seen in children who are in other respects appar- 
ently healthy, even robust ; but the majority are in a more or less debili- 
tated condition, and often are the subjects of digestive disturbances. The 
disease is quite frequent in syphilitic infants; but these simple abscesses 
are to be sharply distinguished from those which result from the breaking 
down of gummata of the skin. Want of cleanliness of the skin is a 
factor of some importance in producing the disease. Furunculosis may 
be associated with eczema. The exciting cause in all cases, as shown by 
recent investigations, is the entrance of the staphylococcus pyogenes 
aureus, sometimes with other organisms, into the follicles of the skin- 
Treatment. — The general treatment is to be directed toward any 
disturbance of digestion or nutrition which is present. Tonics are indi- 
cated in most cases, but no reliance can be placed upon drugs such as 
sulphid of calcium or the hypophosphites, in arresting the disease. Local 
treatment should have for its first object thorough cleanliness of the skin. 
This is best secured by frequently bathing the parts affected with a 1 to 
5,000 solution of bichlorid. Single furuncles may often be aborted by 
touching them with pure carbolic acid or the application of Bier's cups. 
In our experience the best plan of treating the multiple small furuncles, 
is to delay incision until they have pointed, then to incise and empty the 
follicle completely by compression. Where the abscesses are of large size 
and upon the scalp, it is wise to make compression by applying a snug 
bandage for a day. For general furunculosis or the continual recurrence 
of larger abscesses the use of staphylococcus vaccines is altogether the 
most effective treatment. While autogenous vaccines are perhaps prefer- 
able, the use of stock vaccines seems in most cases to be equally effec- 
tive, [injections should be repeated every four or five days; beginning 
with fifty millions, the dose may be increased to one hundred millions, 
or even more. The beneficial effects in most cases are very striking and 
the cure permanent. 



932 DISEASES OF THE SKIN 



GANGRENOUS DERMATITIS 



This is not a frequent disease, and is seen almost exclusively in in- 
fancy. It may be primary or it may follow other diseases, and hence has 
been described under many different names, viz., varicella gangrenosa, 
ecthyma, pemphigus gangrenosa, etc. 

The lesion consists in small, discrete areas of inflammation of the 
skin, ending in necrosis. In the primary cases there is usually first seen 
a vesicle, about as large as a pea, with a dusky areola; it increases in 
size and becomes a pustule. Crusts form which are quite adherent, and 
on removing them a loss of tissue is seen. The ulcers usually have 
sharp but not undermined edges, often presenting a "punched-out" ap- 
pearance. By the coalescence of several smaller ones, ulcers an inch or 
more in diameter are sometimes formed. 

The primary form of gangrenous dermatitis occurs in wretched, 
poorly-nourished infants, and is most often seen upon the buttocks. In 
this location it may be mistaken for syphilis. The secondary form is 
more common, and usually follows varicella, less frequently vaccinia, or 
impetigo. In such cases the lesion is most often seen upon the upper 
half of the body, especially upon the neck and chest. It follows the ordi- 
nary lesions of varicella and continues usually, in spite of treatment, 
from one to four weeks, in many cases ending fatally. The disease al- 
ways occurs in infants of poor vitality, often in those suffering from 
marasmus, and is seldom seen outside of institutions. It may be accom- 
panied by fever, and other severe constitutional symptoms. 

For the production of the disease, two factors are necessary : first, 
the constitutional condition referred to; and, secondly, the entrance of 
pyogenic germs, usually the streptococcus pyogenes. 

Treatment. — Every means possible should be employed to build up 
the general health of the infant by fresh air, careful feeding, etc. Lo- 
cally, strict cleanliness and antiseptic applications are necessary. The 
best application is a solution of bichlorid (1 to 5,000), or an ointment 
of ichthyol or white precipitate. 

IMPETIGO CONTAGIOSA 

Impetigo contagiosa is a disease characterized by the formation of 
discrete vesiculopustules, occurring most frequently upon the hands and 
face. Cases arc usually seen in groups affecting children in one family 
or instil ul ion. tmpetigo may be communicated from one person to 
another, and spread by auto-inoculation from one part of the body to 
another. 



IMPETIGO CONTAGIOSA 933 

One rarely has an opportunity to see the disease until vesicles have 
formed. These are usually from one-fourth to one-half inch in diam- 
eter, and are flaccid, never distended. Later, their contents become 
slightly yellowish; then they rupture and dry, forming thick yellow 
crusts, which have the appearance of being "stuck on," the surrounding 
skin being quite healthy. After the crusts fall off, a small red patch 
remains, which slowly fades. The true skin is not involved, except in 
poorly nourished, cachectic subjects, as a result of continued local irrita- 
tion, like scratching. Under such conditions ulceration may occur. 
Instead of the small vesiculopustules described, bullae from one to two 
inches in diameter may form, filled first with serum, afterward with 
sero-pus. Very little inflammation is seen about these patches, and in 
most cases the intervening skin is normal. 

The favorite seat of the eruption is the face, especially about the 
chin, next the hands, the neck, the feet and legs, the forearms, and the 
scalp; it is rarely seen upon the abdomen, and never upon the back. 
There may be only half a dozen vesiculopustules, or from thirty to forty 
may be present. The smaller ones sometimes coalesce and form others 
of considerable size. Itching is never a prominent symptom, and in 
most cases it is absent altogether. 

The usual duration of impetigo contagiosa is two or three weeks; it, 
however, runs no regular course, and by continued auto-inoculation may 
last much longer than this. 

The studies of Gilchrist point to a streptococcus of low virulence as 
the cause of this disease. European investigators, however, have more 
often found the staphylococcus pyogenes aureus in the vesicles. Im- 
petigo contagiosa may occur in any child, but is seen most frequently in 
one who is poorly nourished. 

The diagnosis is not often difficult, and is made by the following 
features, viz., the occurrence of several cases together, the isolated 
vesiculopustules situated upon the face and hands, the slight itching, 
and the prompt cure by local measures only. The bullous form, how- 
ever, is frequently confounded with pemphigus; many cases in which 
the diagnosis of pemphigus is made are examples of impetigo. 

Treatment. — This is simple and usually very effective. The crusts 
are to be softened and removed by thoroughly washing the part with 
soap and water or a bichlorid solution, after which the white precipitate 
ointment, combined with three parts of vaseline, should be applied. 

URTICARIA 

Urticaria is a frequent disease in early life, and presents some fea- 
tures, particularly in infants and young children, which are quite dif- 



934 DISEASES OF THE SKIN 

ferent from those seen in adults. This is due to the fact that papules 
and vesicles, and occasionally pustules, are associated with the wheals. 
As the wheals quickly subside, it frequently happens that the other 
lesions mentioned are the only ones present. This fact has given rise 
to considerable confusion in names, and the urticaria of infancy has 
been called lichen urticatus,, urticaria papulosa, strophulus, etc. It is 
now pretty generally agreed that the clinical picture, which is a familiar 
one, belongs to a single disease, and that this is urticaria. 

The initial lesion is the wheal, but on account of the extreme suscep- 
tibility of the skin in young children, the process is more intense than 
in older patients, so that it may result in the formation of an inflam- 
matory papule or a vesicle. In a few hours the wheal may subside, and 
only the papules or vesicles remain, and without a good history the dis- 
ease may be a very obscure one. The papules and vesicles occur with 
greatest frequency upon the hands and feet, particularly the palms and 
soles. 

The more severe form of the disease in poorly nourished children 
is sometimes accompanied by a pustular eruption, and there may even 
be deep ulceration (ecthyma). The usual appearance of the eruption is 
a number of small inflamed red papules whose tops are covered with 
crusts, the result of scratching. The eruption may be limited to the 
extremities or it may be general. It is as a rule more severe in regions 
accessible to scratching. 

There is usually severe itching, which leads to loss of sleep, and often 
in this way the disease affects the general health of the child. The urti- 
caria of older children does not differ essentially from the same disease 
in adults. The alternation of urticaria and asthma is occasionally met 
with. 

The character of the eruption in urticaria and even its distribution 
often suggest scabies; and unless one has had an opportunity to wit- 
ness the development of the lesions, a differential diagnosis may be very 
difficult, as almost every lesion, except the wheal, may be identical in 
both diseases. Other cases may resemble varicella. 

Urticaria in early life is most frequently the result of some disturb- 
ance in the digestive tract. Almost any sort of derangement may pro- 
duce it, the exciting cause varying with the patient. 

Treatment. — The milder forms of urticaria usually respond quickly 
to treatment; but when it is severe and has existed for several weeks, it is 
one of the most troublesome and intractable skin diseases of childhood. 
The treatment is to be directed primarily toward the condition of the 
digestive organs. Children should be put upon a very simple diet, al- 
ways excluding sweets, and usually fruits, especially raw fruits. The 
bowels should be kept open by calomel, a nightly dose of castor oil, or a 



SCABIES 935 

morning dose of magnesia. If the urine is excessively acid and scanty, 
alkaline diuretics should be given. 

All local causes of irritation, such as rough flannel underclothing, 
should be removed. The sleep may be so much disturbed as to require 
the use of trional or bromid and chloral. 

The local irritation and itching may be relieved by a very dilute 
solution of the subacetate of lead or carbolic acid, or by diluted vinegar, 
or the fluid extract of hamamelis, or bicarbonate of soda, and water. 
In severe urticaria almost immediate relief may be obtained by the hypo- 
dermic injection of three to eight drops of a 1-1000 solution of epineph- 
rin; the relief often lasts twelve to twenty-four hours. When pustules 
are present, the white precipitate ointment may be used, combined with 
four parts of vaseline; in the papular and vesicular forms, an ointment 
of ichthyol, one-per-cent strength. In many cases the improvement in 
the general health by the use of tonics, change of air, etc., will accom- 
plish more than any measures directed especially to the relief of the 
urticaria. 

SCABIES 

Scabies is a contagious disease due to the burrowing into the skin of 
the female acarus, with secondary lesions which result from scratching. 

The burrowing of the acarus is usually where the skin is thinnest — 
viz., between the fingers, on the flexor surfaces of the wrist, the axillae, 
and, in males, the genitals. It is not seen upon the face, except in in- 
fancy, when infection may occur from contact with the breasts of the 
mother. The lesion excited by the acarus is usually a papule or a vesicle, 
sometimes a pustule. In some cases no evidences of inflammation are 
present, but in infants and young children they may be marked — pustu- 
lar eruptions being frequent and often extensive, especially upon the 
hands and feet. The characteristic burrow is from one-fourth to one-half 
inch in length, and appears as a fine brown or black line, at the end of 
which the acarus may be discovered as a small white speck. The burrows 
are often difficult to find in infants. They are generally to be seen along 
the ulnar border of the hand and between the fingers. The intensity of 
the inflammatory lesions varies greatly in different cases; in some they 
are very few, while in others, particularly in delicate, cachectic, and 
neglected children, they are sometimes very severe, so that the skin of 
the affected part is nearly covered with pustules. These secondary lesions 
are due to infection by the streptococcus or staphylococcus. A pustular 
eruption upon the hands should always suggest scabies. The lesions 
which result from scratching may be found on any accessible portion 
of the body. They are usually at first linear, bloody marks, but after 



936 DISEASES OF THE SKIN 

a time these may not be visible. In little children urticaria is often 
associated. 

The diagnosis of scabies is usually quite easy, as several children in 
a family are likely to be affected, particularly if they occupy the same 
bed. The diagnostic features of the eruption are the presence of papules, 
vesicles, or pustules, especially upon the hands, wrists, and genitals. A 
careful examination with a lens will usually disclose some of the char- 
acteristic burrows, or even the acarus. In infancy, scabies may be easily 
confounded with the vesicular form of urticaria, unless the development 
of the lesions has been observed. 

Scabies' may always be cured, provided sufficient precautions are taken 
to prevent re-infection. This necessitates boiling or baking, not only the 
patient's clothes, but all the bedding as well. 

Treatment. — This should always be begun by a hot bath, in order to 
soften the epithelial scales about the burrows. The body should be thor- 
oughly scrubbed with soap and water, preferably with a nail-brush, the 
bath being continued for at least half an hour. It is well to do this at 
night. After the bath, the body is anointed with the parasiticide, which 
should be thoroughly rubbed into the skin, clean clothing applied, and 
the child put into a perfectly clean bed. In the morning the ointment 
may be washed off, but none of the clothing previously worn should be 
put on. This treatment is to be repeated on two or three successive 
nights, and if thoroughly done it will effect a cure. The ordinary sul- 
phur ointment is too irritating for use in little children, and one of the 
following may be substituted: /?-naphthol, 15 parts; creta preparata, 10 
parts; vaseline, 100 parts (Kaposi); or, precipitated sulphur, 1 part; 
balsam of Peru, 1 part; vaseline, 8 parts; or the simple balsam of Peru 
may be applied without dilution. After the use of the parasiticide there 
is generally required, for a few days, some soothing application like those 
mentioned in the chapter upon Eczema. 



TINEA TONSURANS— RING-WORM OF THE SCALP 

Ring-worm of the scalp is a very frequent disease in institutions for 
children, often occurring as an epidemic. According to Crocker, the 
primary lesion consists in a red papule surrounding a hair, which soon 
increases to a small circular patch; this spreads at its outer margin, 
gradually increasing in size until it is from one to two inches in diameter, 
Inil rarely larger than this. Sometimes several of the patches coalesce. 
These affected areas always have rounded borders, and are sharply out- 
lined. Here I he hairs are very brittle, and often broken off close to the 
scalp, so that the area may appear to be bald. Where they have not 



TINEA TONSURANS— RING- WORM OF THE SCALP 937 

fallen off, the hairs have lost their luster. The stumps of the broken 
hairs point in all directions. 

The fungi which produce the disease belong chiefly to the group of 
small spored fungi or microsporons. Of the several microsporons that 
have been shown to have etiological significance, the microsporon Au- 
douini is the one of importance in this country. The large-spored fungi 
(tricophyton crateriforme or tricophyton acuminatum) are responsible 
for a small proportion of cases. The fungi penetrate the shaft of the 
hair, both the spores and the mycelium being seen under the microscope. 
The spores are present in great numbers in the hair, but the mycelium is 
most abundant in the scales. The amount of inflammation found in the 
diseased areas varies much in the different cases. There may be only a 
scaliness of the scalp, or a formation of pustules in the hair follicles, the 
hairs loosening and falling out in consequence. In young infants, where 
the hair is scanty and thin, the disease resembles tinea circinata — i. e., 
it is superficial, and the hair follicles are often not involved. Children 
of all ages are liable to tinea tonsurans. It flourishes particularly in 
institutions and among those children who are dirty and generally neg- 
lected. 

The diagnostic feature of the disease is the presence of scaly patches, 
with loss of hair. The patches are usually circular, and by examination 
with a lens the stumps of broken hairs are seen all over the diseased 
areas. By a microscopical examination the fungus is discovered. In 
typical cases the diagnosis is easy if the process is at all advanced, but 
there are many atypical forms and many mild cases where the recogni- 
tion of the disease is difficult. The symptoms are often masked by the 
inflammatory conditions present. The disease may be confounded with 
seborrhea ; but in the latter the lesion is diffuse, never sharply defined ; 
there is general thinning of the hair over the scalp, and never the 
stumpy, broken hairs. Psoriasis has points of resemblance; but it is 
usually found on other parts of the body, especially the knees and el- 
bows, and upon the scalp the patches are more numerous and smaller. 
In eczema the loss of hair in circumscribed patches is never seen, nor 
are the broken stumps. 

Tinea tonsurans is always curable, provided the patient can be kept 
under close surveillance, and treatment thoroughly carried out, but it is 
particularly obstinate. There is no tendency to spontaneous recovery 
except toward puberty, when many of the cases recover even without 
treatment. In a recent case, treatment must usually be continued for 
several weeks or months, and in chronic cases from six months to one 
year, with the closest watchfulness. 

Treatment. — The great difficulty in treatment is to get the parasiti- 
cide deeply enough into the scalp to reach the fungus, since tin's is often 



938 DISEASES OF THE EAR 

at the very bottom of the hair follicles. As a first step, the hair should 
be cut short all over the patch and for at least an inch beyond it; this is 
necessary in order to get at the diseased part and to detect new foci of 
infection early — if possible before the fungus has extended deeply into 
the follicles. The parasiticide should be applied not only upon but 
around the patch, and the entire scalp should be washed thoroughly two 
or three times a week. To prevent the disease spreading, all the scales 
are to be kept softened by the use of carbolic soap. The hair should 
not be brushed, as this tends to scatter the spores and spread the disease. 
All patients, while under treatment, should wear a cap of muslin or 
oiled silk, or one lined with paper, in order to prevent infecting others. 
In institutions, affected children should invariably be isolated. 

To destroy the fungus almost every germicide on the list has been 
advocated at one time or another, which proves that the disease is a very 
obstinate one, and that no one application is invariably successful. Cure 
depends more upon persistent treatment than upon the drugs used. 
Those which have the sanction of the widest use are the tincture of 
iodin, the bichlorid, white precipitate and oleate of mercury, /J.naphthol, 
chrysarobin, creosote, carbolic acid and croton oil. As a vehicle for oint- 
ments, adeps lanae (lanoline) is greatly to be preferred to vaseline or 
lard. Epilation is necessary in many cases as an accessory to the appli- 
cation of germicides, particularly in older children. The X-ray has 
been employed by Sabouraud, Noire and others. The greatest care 
should be exercised in its use or permanent baldness may result. 



CHAPTER VI 

DISEASES OF THE EAR 

ACUTE OTITIS 

Otitis is a frequent affection during infancy and early childhood, 
attacks usually occurring in the cold season. Of all the inflammatory 
conditions which may be met with in early life, there is perhaps none 
which more frequently gives rise to obscure febrile symptoms than this. 

Etiology. — Acute otitis is, as a rule, a secondary disease, and is gen- 
erally preceded by some infectious process in the rhinopharynx. The 
usual avenue of infection is the Eustachian tube. 

While it is most commonly seen following simple rhinopharyngitis, 
the most severe forms of otitis follow scarlet fever, epidemic influenza, 
measles, diphtheria, or pneumonia. The entrance of fluids through the 



ACUTE OTITIS 939 

Eustachian tube from the nasal douche or nasal syringing may cause 
acute otitis. It sometimes results as an extension of inflammation from 
meningitis, especially the cerebrospinal form. Otitis is very common in 
hospital patients, especially poorly nourished infants. In them it is 
found with little or, more frequently, with no evidences of a rhinopharyn- 
gitis. 

The microorganisms concerned in the production of acute otitis 
vary somewhat with the condition of which it is a complication. In the 
order of frequency there are found the staphylococcus aureus, the pneu- 
mococcus, the streptococcus, and the influenza bacillus. Mixed infections 
are very common. In cases complicating diphtheria, the Klebs-Loeffler 
bacillus may be found with any of the forms mentioned, or may occur 
alone. In chronic cases any of the pyogenic organisms may be present, 
and not very infrequently the tubercle bacillus. 

Lesions. — The ordinary course of events in the pathological process 
is, first, acute hyperemia and swelling of the mucous membrane of the 
rhinopharynx, which extends into the Eustachian tube, causing obstruc- 
tion more or less complete. The inflammatory process may be limited to 
the tube, or it may extend to the mucous membrane lining the middle 
ear. 

There are two varieties of acute inflammation of the middle ear: (1) 
The catarrhal form, which usually accompanies simple catarrh of the 
rhinopharynx or complicates measles. This is an inflammation of the 
mucous membrane merely, and its products are serum and mucus or 
muco-pus. It is generally confined to the lower part of the tympanic 
cavity, and is the form most frequently seen in infants. (2) The puru- 
lent or phlegmonous form, which affects older children principally. This 
is a much more serious inflammation, and is often excited by the infec- 
tious catarrh of scarlet fever, or diphtheria. In this variety microor- 
ganisms find their way into the middle ear in great numbers, and set up 
an inflammation of a more virulent type, which may involve not only 
the mucous membrane lining the tympanum, but also the cellular tissue 
in the upper part of the tympanic cavity. The lining membrane of the 
mastoid cells is involved in many, if not all, of the cases. 

The catarrhal form of inflammation frequently subsides in a few 
days with proper treatment, the only result being a slight deafness, 
which is temporary. The phlegmonous form causes a stoppage of the 
Eustachian tube, rupture or sloughing of the tympanic membrane, and 
discharge of the products of inflammation, or rarely pus finds an outlet 
by burrowing between the cartilages. The inflammatory process may 
extend to the bones, causing necrosis of the ossicles or the bony walls of 
the tympanum. The remote results are periostitis and necrosis of the 
petrous bone, pachymeningitis, infections thrombosis of the lateral sinus, 



040 



DISEASES OF THE EAR 



general purulent meningitis, and cerebral abscess. These will be con- 
sidered under Complications. 

Symptoms. — These are usually few in number, but present great 
variability as regards their combination and intensity. The two most 
constant symptoms are pain and fever. In a typical case in an infant, 
there is generally at the beginning some discharge from the nose, slight 
congestion of the pharynx and tonsils, and a temperature of 100° to 
102° F. There is nothing characteristic about this catarrh. After two 
or three days the objective symptoms subside, but the infant continues 
to be restless, worries much of the time, wakes frequently at night with 
a start, nurses poorly, and the temperature remains elevated, usually 
from 100° to 103° F. (Fig. 150). The infant seems decidedly ill, and 




Fig. 150. — Temperature Chart of Acute Otitis Following Influenza, in a Child 

Three Years Old. 



yet j io very definite symptoms are present. Earely there is marked ten- 
derness about the ear, and the child refuses to lie upon the affected side, 
or shows signs of pain when the ear is touched. After a week or ten 
days spontaneous rupture of the drum membrane takes place, and sub- 
sidence of the constitutional symptoms follows. In some cases there is 
seen only a high temperature, ranging from 101° to 104° F., which per- 
sists for several days without outward evidences of pain or other signs 
of inflammation, and the discharge is the first symptom which leads the 
physician to suspect disease of the ear. In other cases there is marked 
<1 ulness, apathy, anorexia, and sometimes nausea and vomiting, but for 
several days no evidence of pain; the temperature may be but little ele- 
vated. Thus, in most of the attacks seen in infancy, pain is not marked, 
and it is litis fact which so often leads to the obscurity of the symptoms. 
In older children the symptoms are more characteristic. Pain is 



ACUTE OTITIS 



941 



usually sharp and severe, and is complained of early in the attack. The 
temperature is nearly always elevated two or three degrees, and occa- 
sionally it is 103° or 104° F. (Fig. 151), with severe headache, extreme 
restlessness, and even delirium or convulsions, so that meningitis may be 
suspected. 

The inflammation does not necessarily go on to suppuration and rup- 
ture. There are even more frequently seen, accompanying ordinary 
head-colds or mild attacks of influenza, cases in which the pain is quite 
severe for twenty-four or thirty-six 
hours, and accompanied even by a mod- 
erate elevation of temperature, and yet 
which rapitlly subside without further 
symptoms. 

In infants suffering from malnutri- 
tion or marasmus, otitis often comes on 
without any objective symptoms, the 
first thing noticed being the discharge. 

Of all the symptoms, fever is the 
most constant, and is present in all 
cases except those just mentioned. 
The usual range of temperature is from 
100° to 102° F.; exceptionally it may 

be from 103° to 105° F. The course of Fig. 151.— Temperature Chart of 
the temperature is irregular. After 
spontaneous rupture or incision of the 
drum membrane the temperature usu- 
ally falls, but often not immediately. 
Pain is more marked in older children 
than in infants, because in the latter 
the drum membrane is not so firm, 
yields more readily, and ruptures ear- 
lier. Tenderness is sometimes elicited by pressure, especially just in front 
of the external auditory meatus ; there may be increased sensitiveness of 
all parts of the ear and even of the whole side of the head ; but no reliance 
should be placed upon the absence of such symptoms in excluding otitis. 
Children often complain of noises in the ear. Cerebral symptoms are 
infrequent, and occur chiefly in cases not receiving proper early treat- 
ment ; they may indicate meningeal congestion, or, less frequently, local- 
ized meningitis or thrombosis. 

In secondary otitis, especially when complicating severe scarlet fever, 
diphtheria, measles, or typhoid fever, all subjective symptoms are fre- 
quently wanting; unless the ears are examined the disease may be over- 
looked until rupture has taken place. 



Day 
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Acute Otitis Aborted by Early 
Paracentesis. Boy nine years 
old; attack followed a mild ca- 
tarrh; severe pain in both ears 
began in afternoon of second day. 
Both drum membranes found 
acutely congested and bulging; 
incision followed by free hemor- 
rhage and immediate relief of pain. 
No suppuration occurred; pa- 
tient well on fifth day. 



942 DISEASES OF THE EAR 

The local appearances in the early stage are marked redness and con- 
gestion; later there is distinct bulging. If perforation has taken place, 
its site may or may not be visible, but its existence may be assumed if 
bubbles of air are seen deep in the canal, and if, in the absence of a fu- 
runcle or marked eczema, much mucus or pus is present, as inflammation 
of the external canal seldom causes a discharge. In the catarrhal form 
the discharge is at first sero-mucus and quite profuse; later it is puru- 
lent. In the phlegmonous form it is always purulent, and liable to a 
sudden arrest with an increase in the constitutional symptoms. The pus 
sometimes burrows between the cartilages and escapes externally behind 
or at the side of the ear. Earely it may work its way anteriorly and 
cause an abscess in the parotid gland. 

Diagnosis. — Otitis in infancy is frequently obscure, because the 
patient is too young to direct attention to the seat of pain, or because the 
pain is slight or absent. The temperature is almost invariably elevated, 
and the usual problem presented is to discover a cause for this fever. 
The examination of the ears with a speculum should be made as a matter 
of routine in all children with fever, especially those in whom the cause 
of the fever is not perfectly clear. Otherwise many cases will be over- 
looked. A leucocytosis of 15,000 to 20,000 is almost invariably found. 
Local tenderness, deafness, or noises in the ears are significant when 
present, but are often wanting. Otitis is so common a cause of high 
temperature in infants during the cold season, that one should always 
have it in mind. 

Complications and Sequelae. — Remote consequences are most likely 
to be seen in cases following scarlet fever, probably because of their 
severity, particularly when early treatment has been neglected. 

Mastoiditis. — This is the most frequent complication of acute otitis. 
In infancy the mastoid process is small and contains but a single cavity, 
the mastoid antrum, which communicates directly with the vault of the 
tympanum. It is probable that in every severe case of acute suppurative 
otitis there is some pus in the antrum. This is usually discharged into 
the middle ear after the tympanic membrane is incised or ruptures spon- 
taneously. The principal cause of mastoid involvement is want of proper 
early treatment in acute otitis, particularly the practice of allowing these 
cases to take their natural course instead of securing early drainage by 
incision of the drum membrane. 

The important symptoms of acute mastoiditis are fever, mastoid ten- 
derness, and swelling. If mastoiditis develops rapidly after acute otitis 
the temperature may be high — 103° to 105° F., and the leucocytosis is 
somewhat greater; if it develops gradually and appears late the tem- 
pi ratlin' may be scarcely above 100° F. Abrupt cessation of an ear dis- 
charge should always arouse suspicion. It is always difficult to de- 



ACUTE OTITIS 943 

termine the presence of a slight amount of mastoid tenderness, but 
persistent tenderness of one side only is significant. It is often most 
marked close behind the auricle just over the antrum. Care should be 
observed in ascertaining tenderness to make pressure only over the mas- 
toid. When there is eczema or furunculosis of the canal pushing for- 
ward the auricle causes pain. The early swelling is due to edema from 
periostitis ; later there may be an accumulation of pus beneath the perios- 
teum. Post-auricular abscess causes a very characteristic swelling, the 
ear standing out from the head. It is usually due to spontaneous rup- 
ture through the outer bony wall just over the antrum; it may occur 
when there has been no discharge from the ear; but mastoiditis prac- 
tically never occurs as a primary hematogenous infection and examina- 
tion of the drum membrane will reveal unmistakable evidences of an 
otitis media. It is a frequent result of severe cases of acute mastoiditis 
not operated upon, especially in young children. 

The characteristic otoscopic appearances of acute mastoiditis are, 
bulging of ShrapnelPs membrane and drooping of the upper posterior 
wall of the external auditory canal due to edema. 

Meningitis. — This is very rare in infants, but is more common in 
older children. There may be a localized pachymeningitis with the for- 
mation of pus — an epidural abscess — or, less frequently, general puru- 
lent meningitis. It may be secondary to other lesions, such as throm- 
bosis of the lateral sinus, or the rupture of a cerebral abscess, but is usu- 
ally due to infection through the roof of the tympanum, or along the 
internal auditory meatus. Meningitis may occur either with acute or 
chronic cases. Its symptoms are those of a severe acute meningitis; its 
duration is short; its termination almost invariably in death. 

Cerebral Abscess. — This is due to a direct extension of the infection 
from the bone, veins, or dura mater. In about two-thirds of the cases 
the abscess is in the temporosphenoidal lobe. The next most frequent 
seat is the lateral lobe of the cerebellum. Korner states that disease of 
the mastoid and middle ear leads to cerebral abscess, and disease of the 
labyrinth to cerebellar abscess. Abscesses may be complicated by throm- 
bosis or by meningitis. They are often latent until just before death, 
which more frequently occurs from the development of purulent menin- 
gitis than from any other cause. They are rare except in otitis of long 
standing. (See Cerebral Abscess.) 

Thrombosis of the lateral sinus may be simple or septic. In the 
former there is occlusion of the vessel by a fibrinous clot ; in the latter 
there are in addition, microorganisms. 

Simple thrombosis causes no important symptoms. Septic throm- 
bosis is relatively infrequent and causes very marked and severe symp- 
toms. It follows operation upon the mastoid, or occurs as a complication 



944 DISEASES OF THE EAR 

of mastoiditis quite apart from operation. The temperature is usually 
of a high and widely fluctuating type, and there may also be chills with 
older children, but this cannot be depended on as evidence of throm- 
bosis in infants or young children. In some cases the constitutional 
symptoms, except fever, may not at first be severe, but may suddenly 
become very grave. Marked cerebral symptoms often develop rapidly, 
and death may follow in from twelve to twenty-four hours. At autopsy 
there may be found a soft broken-down clot in the sinus, which may 
extend into the jugular. It may be followed by secondary lesions of a 
general pyemia, or by localized or general meningitis. Blood cultures 
usually give positive information, but it is often necessary to make sev- 
eral before organisms are found. 

The labyrinth is infrequently involved, although cases are recorded 
by Pye, Phillips, and others, in which the necrosis and discharge of the 
entire labyrinth has occurred after scarlet fever. In most of these cases 
the deafness was complete, and in several vertigo was present. 

Facial paralysis rarely occurs in the acute cases, but accompanies a 
considerable proportion of the chronic ones. It is especially seen in the 
tuberculous variety. It is due to an extension of the inflammatory 
process from the bone to the seventh nerve, where it passes through the 
canal. The symptoms are those of ordinary peripheral facial palsy. 
The prognosis is good for recovery in the non-tuberculous variety. 

Treatment. — Something may be done in the way of prophylaxis. It 
is of the first importance to secure a normal condition of the mucous 
membrane of the rhinopharynx by the removal of enlarged tonsils, ade- 
noids, etc. The occasional attacks of otitis accompanying these con- 
ditions are pretty sure to be followed by more serious trouble unless they 
are relieved. Repeated attacks of otitis media in childhood are responsi- 
ble for fully eighty per cent of the cases of chronic catarrhal deafness 
in adult life. Whether during attacks of measles or scarlet fever, much 
can be done to prevent otitis, is still a mooted question. We believe the 
risks of infection of the middle ear when judicious nasal syringing is 
employed are less than when nothing is done to cleanse the rhinopharynx. 

The medical treatment of acute otitis aims at the relief of pain and 
arrest of the inflammation. If the case is seen in the early stage the 
introduction of a few drops of a solution of epinephrin into the nostrils 
and cars and repeated every two or three hours, will sometimes abort 
an attack. Carbolic acid in olive oil in a strength of ten per cent has 
an undoubted effect in allaying inflammation if applied in the early 
Btages. This may be aided by free catharsis and the application of dry 
heal. Laudanum should not be dropped into the ear as is so often done 
in domestic practice; but there is no objection to a few drops of a four- 
per-cent solution of cocain, which may relieve intense pain. If the child 



ACUTE OTITIS 945 

is not soon comfortable, an opiate should be given which may not only 
relieve pain, but may have a favorable influence upon the inflammation. 

A continuance of pain in spite of these measures, with an increas- 
ing temperature, calls for operative interference. But a more reliable 
guide is the appearance of the drum membrane. If in addition to these 
symptoms there is mastoid tenderness immediate paracentesis of the 
drum membrane is imperative. An early incision is usually followed by 
a discharge of blood only; but tension is relieved, pain disappears, and 
the inflammation often quickly subsides without the formation of pus. 
(See Fig. 151.) Much suffering is thereby avoided; the wound rapidly 
heals, and much less damage is done than by allowing the disease to go on 
to a spontaneous rupture. Later incision may be required either for the 
relief of pain or for the evacuation of pus to prevent, if possible, the dis- 
ease from spreading to the bony parts. The advantages of early paracen- 
tesis in acute otitis can hardly be overstated. Properly performed, it is 
free from risk, causes little or no shock, and should be advised in many 
cases even in which the indications are not so clear as those above de- 
scribed. Incision of the drum membrane should be favored in cases of 
doubt rather than waiting for more definite indications with the attend- 
ant risks of delay. 

In the secondary otitis of scarlet fever, measles, and diphtheria, the 
indications for paracentesis are usually to be derived from the appear- 
ance of the drum membrane alone, other symptoms being absent or 
masked by the primary disease. 

After incision or spontaneous rupture of the drum membrane, to pre- 
vent the wound from closing and to cleanse the parts, the ear should be 
syringed every two or three hours with a warm saline solution, or a 
saturated solution of boric acid. A bulb ear-syringe of soft rubber or 
a fountain syringe may be used. The external auditory canal should 
be carefully dried after irrigation to prevent maceration and the develop- 
ment of eczema. 

In most acute cases the discharge ceases in from one to three weeks ; 
should it continue longer, some measures for checking it may be used. 
The use of a few drops of a 1 to 3,000 solution of bichlorid in sixty-five 
per cent alcohol after syringing is of some value. It should be used with 
a medicine dropper. When the discharge has become fetid, syringing 
once a day with a solution of peroxid of hydrogen (1 to 2) is often 
useful. A persistent discharge often depends upon the fact that the 
child's general condition is poor, and improvement in this is more im- 
portant than any variation in local treatment. 

\Vhen symptoms pointing to acute mastoiditis are present, early 
free incision of the drum membrane is indicated, and a mastoid ice- 
bag should be applied intermittently for twenty-four to thirty-six hours. 



946 DISEASES OF THE EAR 

In addition, in older children, the artificial leech may be placed over the 
antrum or the mastoid tip. With these measures the inflammation often 
subsides. Eegarding operation upon the mastoid, our belief is that 
it is now performed too frequently and with insufficient indications, 
especially in infancy and very early childhood. The operation is a serious 
one, and at this age its immediate risks are considerable. We have 
known of a number of deaths directly connected with it, and of others 
occurring at a later period, where the child was worn out by the long 
after-treatment, dying perhaps from some intercurrent disease or from 
exhaustion. On the other hand, the dangers to which very young patients 
are exposed who are not operated upon have been exaggerated. In 
our experience, meningitis, sinus thrombosis, and cerebral abscess do 
not occur in anything like the proportion of cases that the surgeons 
would have us believe. 1 

While fully appreciating the value of the operation, and being quite 
sure that lives are often saved by its timely performance, we would in- 
sist that it be done only with very positive and clear indications. In 
infants, localized tenderness is difficult to determine; and fever after 
acute otitis may be due to many other conditions. In very young pa- 
tients we should therefore insist upon other symptoms before deciding 
to operate. The risks of waiting for clearer indications are much less 
than those attendant on unnecessary operation. Often the cause of the 
temperature is found in the lungs; and not very infrequently a mod- 
erate pulmonary congestion or bronchitis becomes a pneumonia as a con- 
sequence of the prolonged anesthesia necessary for the operation. With 
infants therefore in case of any doubt, as to diagnosis or the progress 

1 The records of the New York Foundling Hospital, with a resident and 
constantly changing population of about 800 infants and young children, showed 
573 cases of acute otitis in five years (1900 to 1904, inclusive). During this 
period there were three extensive epidemics of measles with a total of 1,034 
cases; 166 cases of scarlet fever; 578 cases of diphtheria; and 1,505 cases of 
pneumonia. With the 573 cases of otitis, acute mastoiditis was recognized and 
recorded in but 17 patients. It is not improbable that other mastoid inflam- 
mations were overlooked. In this institution, however, nearly every fatal case 
comes to autopsy, and if an unrecognized mastoiditis had led to a fatal result 
the autopsy records should show it. In the five-year period, 900 autopsies were 
made. There was no instance recorded of abscess of the brain following otitis. 
There were but two examples of acute meningitis following otitis with mas- 
toiditis; but there were 14 cases of acute meningitis secondary to other condi- 
tions— pneumonia, 10; to pericarditis, 2; to empyema, 1; to diphtheria, 1. Dur- 
ing the period mentioned there were 11 mastoid operations performed in the 
hospital, with 6 recoveries and 5 deaths, all from causes directly connected with 
I Ik: operation. 

If mastoiditis follows the otitis which complicates the acute infectious dis- 
of early childhood as often as has been claimed, we must admit that a very 
large proportion of the patients may get well without operation. 



ACUTE OTITIS 947 

of the case, one should invariably decide against operation, or at least 
for postponement. With older children, however, conditions are some- 
what different; diagnosis is easier and the operative risk much less. 

The treatment of chronic otitis and of the associated conditions is 
largely surgical, and belongs to the specialist; but it is extremely im- 
portant that the general practitioner should be familiar with their symp- 
toms, and realize the danger from these neglected cases, not only to the 
function of hearing, but also to life itself. The essential thing in treat- 
ment is that the operation should be thorough enough to secure free 
drainage, and to permit thorough cleansing of the parts. Too much 
can not be said against the expectant treatment of these cases, or against 
the practice of prolonged poulticing. 



SECTION IX 
THE SPECIFIC INFECTIOUS DISEASES 

A mobe accurate knowledge of the causative agents of the various 
infectious diseases has made necessary a revision of the opinions once 
held regarding the manner in which they are communicated. It was 
formerly believed that most of the common contagious diseases were air- 
borne infections. Smallpox and scarlet fever especially were cited as 
examples of diseases which could be conveyed by air currents at a con- 
siderable distance from the body. It was believed that these and other 
contagious diseases were frequently carried by a third person. It is now 
pretty definitely established that such contagion is possible only for a 
very short distance, probably but a few feet from the patient, and that 
communication through a third person is an extremely rare occurrence. 
In the spread of contagious diseases, articles of clothing, toys, books, fur- 
niture and other objects which had been in contact with the patient were 
once regarded as frequent sources of infection. While it cannot be de- 
nied that these are sometimes the vehicles of contagion, this mode of 
spreading these diseases is certainly infrequent. 

Infection, as a rule, is acquired either by contact with or close 
proximity to a person suffering from a contagious disease. By contact 
there may be actual transfer of the organism causing the disease. By 
proximity the specific poison of the disease which is discharged from an 
infected person, usually in the form of minute droplets by coughing or 
sneezing, may be inhaled. In this way whooping-cough, epidemic catarrh 
and measles in the early stage are probably most frequently communi- 
cated. Measles and scarlet fever are often spread in the later stages by 
the discharges from mouth, nose, eyes, ears or glands. 

There are two very important sources of infection which are con- 
stantly overlooked. The first is the unrecognized case, which escapes 
notice, in scarlet fever, because of its mild character; and in tubercu- 
losis, because the early stage is so prolonged. The second source is the 
group of persons known as "carriers." To the latter are very often 
traced epidemics of typhoid fever and diphtheria; rarely, epidemics of 
cerebrospinal meningitis and acute poliomyelitis. Carriers are persons 
who harbor the organisms of infection, usually as the result of a previous 
attack, sometimes because they have been in close contact with the dis- 

949 



950 THE SPECIFIC INFECTIOUS DISEASES 

ease, but are not themselves at the time suffering from it. The recog- 
nition and segregation of these carriers constitute one of the most 
difficult and important problems in connection with the prevention of 
communicable diseases. 

Infection may take place through the inhalation of dust particles 
which contain the specific organism of the disease. The bacilli of tuber- 
culosis, diphtheria and typhoid may survive drying and become a part 
of the dust of the room. While rarely present in the upper air of the 
room, they may be found in places where dust settles, as on floors, win- 
dow-sills, etc. Infection of older children or adults by actual inhala- 
tion of these organisms with dust is probably very uncommon ; but small 
children, playing much on the floor, may easily acquire infection from 
dust upon hands, toys, etc., most often through the mouth. 

There are certain disease organisms that die so quickly after being 
discharged from the body that infection by dust is most improbable. 
Examples of this are the B. influenzae, the meningococcus and the gono- 
coccus. 

Epidemic catarrh spreads so rapidly in epidemics that the evidence is 
stronger in this disease than in any other that it may at times be air- 
borne; but it is more frequently spread through contact or near prox- 
imity to infected persons through coughing, sneezing, etc., or from 
handkerchiefs, clothes, drinking utensils, etc., which have been in con- 
tact with patients. 

General Care. — In most of the contagious diseases discussed in the 
following pages the infectious agent is confined to the discharges from 
the patient's mouth, nose, throat, eyes, ears, sputum or glands. If the 
spread of these diseases is to be prevented, this poison should be destroyed 
as soon as it leaves the body. The physician who is in charge of a patient 
with an infectious disease has a responsibility, not only to the patient and 
those in immediate contact with him, but to the community. As the same 
general directions should be followed with all severe communicable dis- 
eases, they may well be outlined in this introductory chapter. 

The Sick-room. — One with good light and air, so situated as to be 
easily shut off from the rest of the house or apartment, should be 
chosen. An open fire and an adjoining bath-room are very desirable. 
Carpets, rugs, upholstered furniture and all hangings should be removed. 
Only the simplest and most necessary furniture should be left behind 
and such hooks or toys as can be destroyed. An abundant supply of 
hot water should be provided for, a large slop jar, and plenty of old 
muslin and absorbent cotton to bo used in place of handkerchiefs for 
discharges, and a supply of paper bags, in which these can be placed for 
removal. Free ventilation should be secured, and windows should b? 
screened against flies and mosquitoes. The sick-room should be kepi 



GENEPxAL CARE 951 

scrupulously clean; especially should all dust be wiped up daily from 
floors, window-ledges, and railings, with a cloth which has been wrung 
from a 1-1000 bichlorid solution. The cloths used should be kept in the 
same solution. The bed linen should be frequently changed, and kept 
clean. In the room should be a large bowl of carbolic acid, 1 to 40, or 
some similar solution for cleansing the hands. There is no objection 
to the hanging of sheets moistened in carbolic, bichlorid, or other disin- 
fectant solutions before the door, but neither this nor hanging them 
about in the sick-room is to be regarded as having any value in disin- 
fecting the air of the room. They create a false sense of security, and 
often lead to the neglect of thorough cleanliness. 

The nurse should wear a washable cap and gown, which she should 
remove on leaving the room. Eubber gloves are an added protection in 
severe infections. The nurse should not eat in the sick-room. 

The (physician, before entering the sick-room, should remove his coat 
and don a cap and gown, kept hanging outside the sick-room for his 
special use. He should carefully wash his face and hands before leaving 
the room. 

The patient being the source of infection, special care should be 
taken with everything which comes in contact with him. The outer 
clothing, worn when he was taken ill, should be exposed to sunlight for 
at least one day and thoroughly brushed in the open air. Underclothing 
should be boiled for ten minutes and placed in a 5-per-cent solution of 
carbolic acid. Bed-linen should be soaked in the carbolic solution and 
boiled in soapsuds before going to the general wash. Handkerchiefs, if 
used at all, should be treated in the same way. If there is much sputum 
it should be received in paper cups, which should be burned, or in vessels 
containing 5-per-cent solution of carbolic acid. All discharges from 
the mouth, nose, eyes and ears should be collected on old muslin or ab- 
sorbent cotton, thrown into paper bags and burned. Handkerchiefs 
should not be used for this purpose. Special disinfection of discharges 
from the bowels is not needed in the diseases treated in this Section, 
except in the care of typhoid cases. All remnants of food should be 
burned. All dishes, knives, forks, spoons, etc., should be boiled in soap- 
suds and used only by the patient. At the termination of quarantine 
the patient should receive a complete and thorough bath, including the 
bair, with soap and water, and entirely clean clothing put on in an 
adjoining room. Especial care should be given to cleanliness of the 
mouth and teeth. 

The room subsequent to the illness should receive the most thorough 
cleaning. Floors, woodwork and furniture should be thoroughly 
scrubbed with soap and hot water, walls should be wiped down with 
damp cloths wrung from 1-1000 bichlorid solution. After severe infec- 



952 THE SPECIFIC INFECTIOUS DISEASES 

tions like scarlet fever and diphtheria, repapering or repainting should 
be done. Toys and books used in the sick-room should be destroyed or 
sent to hospitals where similar infections are treated. The mattress and 
blankets should be sent to a steam disinfecting place, if one is available; 
if not, they should be exposed for two or three days to sunlight and 
beaten in the open air, to remove all dust. All washable bedding should 
be treated as heretofore mentioned. Not only the sick-room but the 
adjoining room much used by attendants should receive special cleaning. 
Fumigation will be quite unnecessary if the above directions have been 
thoroughly carried out. Its value has always been problematical; it is 
now rapidly being abandoned by health authorities. Its efficacy is in 
no way to be compared to the special cleanliness heretofore emphasized. 



CHAPTER I 
SCARLET FEVER 

(Scarlatina) 

Scarlet fever is an acute, contagious, self-limited disease, one at- 
tack usually protecting the individual through life. The period of incu- 
bation is usually from two to five days ; that of invasion, from twelve to 
twenty-four hours; that of eruption, from four to six days; that of 
desquamation, from three to six weeks. The disease may be communi- 
cated at any time from the first symptom of invasion and even during 
the existence of purulent discharges from the nose or other mucous or 
serous membranes. It is usually ushered in by vomiting, fever, and sore 
throat, and lS characterized by an erythematous rash appearing first 
upon the neck and spreading rapidly over the entire body. Its chief 
complications are otitis, adenitis, and membranous inflammations of the 
pharynx, which frequently extend to the nose, rarely to the larynx. The 
most important sequelae are otitis and nephritis. The constancy of the 
throat infection in scarlet fever strongly points to the pharynx as the 
point of entry of the infection. 

Etiology. — Analogy leads to the belief that scarlet fever is due to a 
microorganism, but as yet its nature has not been discovered. The 
complications are usually associated with the development of a strepto- 
coccus. Some have gone so far as to claim that a streptococcus is the 
ca use of the disease. From present knowledge, however, it appears rather 
to play the role of a secondary or accompanying infection, for the devel- 
opment of which the mucous membranes of a person suffering from 



SCARLET TEVEK 



1)53 



scarlet fever seem to afford most favorable conditions. To the strepto- 
coccus may be ascribed the membranous inflammations of the tonsils 
and pharynx, the otitis, the inflammation of the lymph nodes and the 
cellular tissue of the neck, and probably also the nephritis, endocarditis, 
pneumonia, and joint lesions. In many of the above conditions the 
streptococcus is associated with other pyogenic germs, and in some cases 
with the diphtheria bacillus. 

Predisposition. — The susceptibility of children to the scarlatinal 
poison is much less than to that of measles ; still, it is much greater than 
that of adults. Billington (New York) records observations made in 
twenty-six families living in tenements where little or no attempt at 
isolation was made. In these families there occurred forty-three cases 
of scarlet fever; but forty-seven other children, although unprotected by 
previous attacks and constantly exposed, did not contract the disease. 

Johannessen reports that of 185 children under fifteen years who 
were exposed, twenty-eight per cent contracted the disease; while of 314 
adults, only five per cent contracted the disease. It may be stated that, 
approximately, not more than one-half of the children exposed take the 
disease. The susceptibility is slight in early infancy, but it increases 
until about the fifth year, after which it steadily diminishes. Both sexes 
are equally liable to scarlet fever. Epidemics are more frequent in the 
fall and winter than in summer, and cases occurring in the cold months 
are apt to be more severe. Whitelegge, in 6,000 cases, found the highest 
mortality in the month of October ; and in Caiger's report of 1,008 cases 
this was also the month showing the greatest mortality. 

Incubation. — Of 113 cases 1 in which the period of incubation could 
be accurately determined, it was as follows: 



24 hours or less 6 

2 days 15 

3 " .....28 

4 " 

5 " 

6 " 

7 " 



25 " 

6 " 

15 " 

Q « 



8 days 2 



9 
11 
14 
21 



5 " 
1 case. 
1 " 
1 " 

113 cases. 



Thus in eighty-seven per cent of these it was between two and six 
days, and in sixty-six per cent between two and four days. Speaking 
generally if, after exposure, a week passes without symptoms, the chances 
of infection are very small. A short incubation is more frequently seen 
in severe than in mild cases. 



1 Part of these are from personal observation, but the great majority are 
isolated cases scattered through medical literature, occurring under circum- 
stances which made it possible to determine the exact length of the incubation 
period. 



954 THE SPECIFIC INFECTIOUS DISEASES 

Mode of Infection. — The chief source of infection is the patient him- 
self. It is the mild and unrecognized cases which act as carriers to 
which the spread of the disease is very frequently due. It is somewhat 
doubtful whether the poison of scarlet fever can be conveyed by the 
breath, but infection is chiefly by discharges from the mucous mem- 
branes involved. Whether it can be conveyed by the scales during 
desquamation or by the excretions of the patient — urine, feces and per- 
spiration — is a question of grave doubt. It has not been demonstrated. 
Infection may take place from the carpets or furniture of the sick- 
room and from the clothing of the patient. Toys or books may be 
carriers of the disease. A bouquet of flowers sent from a sick-room 
to an institution has been known to be a vehicle of infection. Cats, 
dogs and other domestic animals in rare instances have conveyed the 
disease. Scarlet feveF is sometimes spread by milk. The simultaneous 
occurrence of a considerable number of cases in a community should 
lead one to suspect the milk supply. All of these sources of infection 
are relatively infrequent. 

The transmission of the disease through a third person is not fre- 
quent, but numerous instances of it are on record. The persons most 
likely to carry it are the nurse and the physician, the latter rarely unless 
there has been very direct contact with the patient, and when the 
interval before seeing the second child is short. The transmission of 
the disease by one who, although living in the house, does not come in 
contact with the patient, is extremely improbable. 

Duration of the Infective Period. — There is no evidence to show 
that the disease is communicable during the period of incubation. It is 
slightly contagious from the beginning of invasion, before the rash 
appears. Infection appears to be most active at the height of the febrile 
period — from the third to the fifth day. 

In simple cases, the average duration of the contagious period may 
be placed at five weeks, or until discharges from mucous membranes 
of the nose and throat, the ears and glandular sinuses have ceased. The 
infectious nature of these discharges has not been sufficiently recog- 
nized. One case is recorded in which scarlatina was communicated 
through a purulent nasal discharge after eleven weeks; another in which 
the opening of a post-scarlatinal empyema in a surgical ward was fol- 
lowed by an outbreak of scarlet fever. 

In winter especially, a chronic pharyngeal catarrh may long contain 
the infective agent. Ashby found, on careful investigation, that from 
two to four per cent of patients discharged from a scarlet-fever hospital 
subsequently conveyed the disease. There is particular danger from a 
child who has recently had the disease sleeping with other children. Line 
records a case in which the disease was contracted in this way after 



SCARLET FEVER 955 

fourteen weeks. It is impossible to say that at. any specified time abso- 
lute safety exists. All patients before being discharged from a hospital 
or released from quarantine in private practice, should be carefully 
examined as to the condition of the mucous membranes, and quarantine 
continued as long as catarrhal inflammations are present. The poison 
of scarlatina clings more tenaciously to clothing, upholstery, and apart- 
ments than that of any other infectious disease, possibly excepting tuber- 
culosis. 

Lesions. — The only characteristic lesions of scarlatina are those of 
the skin and the mucous membranes of the mouth and throat. The skin 
is the seat of an acute dermatitis of variable depth and intensity. There 
is first acute hyperemia, followed by an exudation of serum and cells in 
the corium, especially about the blood-vessels and hair follicles. There 
results a death of the epidermis which is thrown off in the desquamation. 
The mucous membrane of the mouth, tongue, and throat is the seat of 
a catarrhal, membranous, or gangrenous inflammation which rarely in- 
vades the larynx, but very frequently the middle ear and nose. The 
entire esophagus is often the seat of an intense congestion. From the 
ear the infection may extend to the mastoid cells, the meninges, or the 
brain, and from the nose to the accessory sinuses, particularly the an- 
trum of Highmore. All the lymph nodes about the neck may be 
involved, the infection ending in cell-hyperplasia, suppuration, or ne- 
crosis. The cellular tissue of this neighborhood may also become infil- 
trated, this being followed sometimes by suppuration and occasionally 
by gangrene. 

The most constant change throughout the body, according to Pearce, 
is hyperplasia of the lymphoid tissue, which is seen everywhere. The 
other lesions are degenerations due to the scarlatinal poison alone, or 
in conjunction with the various forms of secondary infection, or to 
the latter alone. The most important are : fatty degeneration of the 
heart; areas of focal necrosis in the liver; acute degeneration of the 
kidney or acute diffuse nephritis; proliferation of the cells of the 
Malpighian bodies of the spleen; bronchopneumonia, gangrene, or 
abscess of the lung; pleurisy, which is often purulent; endocarditis, 
pericarditis; abscesses in the cellular tissue and inflammation of the 
joints. These visceral changes will be considered more fully under 
Complications. 

Symptoms. — Invasion. — As a rule, the invasion of scarlet fever is 
abrupt, the symptoms at the onset usually being directly in proportion 
to the severity of the attack. In the majority of cases there is vomiting, 
a rapid rise in temperature, and soreness of the throat. Often the 
vomiting is repeated ; it is frequently forcible, and without nausea. In 
severe cases the rise in temperature is very rapid, to 104° or 105° F. ; 



95G THE SPECIFIC INFECTIOUS DISEASES 

in the mildest cases it may not be above 101° F. A child may complain 
of soreness of the throat, or the throat symptoms may be entirely ob- 
jective. In most severe cases there is a uniform erythematous blush 
covering the pharynx, tonsils, and fauces, but on the hard palate it ap- 
pears as minute red points. The appearance of this is usually coincident 
with the rise in temperature. Occasionally membranous patches may be 
seen upon the tonsils the first day, but generally not before the third 
or fourth da}'. In mild cases the throat shows only a very moderate 
congestion. Severe cases are sometimes ushered in by convulsions, 
especially in very young children. Diarrhea is not uncommon in 
summer. There is general prostration, which is directly proportionate 
to the height of the fever. *■ 

Eruption. — This usually appears from twelve to thirty-six hours 
after the first symptoms of invasion ; exceptionally, not until the third 
or even the fifth day. A later appearance than this is somewhat 
doubtful, for the rash not infrequently recedes and reappears, having 
been overlooked in the first instance. In 108 cases tabulated the duration 
of the rash was as follows : 

Two days or less 5 cases 

Three to seven days 81 " 

Eight to eleven days 16 " 

Over eleven days 4 " 

Recurring 2 " 

These figures are confirmed by the observations of most writers, 
that the rash lasts from three to seven days. The full development of 
the rash is generally seen in from twelve to twenty-four hours from its 
first appearance, and not infrequently the whole body is covered in the 
course of four or five hours. Its first appearance is almost invariably 
upon the neck and chest. Its color is red rather than scarlet, and on 
close inspection it is seen to be made up of very minute points upon 
a reddish ground giving the appearance of a uniform blush ; or the back- 
ground may be wanting and only the punctate eruption shows. These 
points are the papillae of the skin and hair follicles. The rash usually 
covers the entire body except the face. Even in cases with intense 
eruption the central part of the face usually escapes, though elsewhere 
the eruption may be as bright as upon the body. There is often a 
peculiar pallor about the mouth which is characteristic. The appearance 
of the eruption in dark-skinned races is much modified and often diffi- 
cii U of recognition. In the negro the palms and soles may be the only 
plates where the eruption can be distinguished. Here may be seen a 
bright red blush or a fine papular eruption. 

Variations in the eruption are very frequent and very puzzling. 



SCARLET FEVER 957 

They occur especially in the mild and in the most severe cases. 

In the mild cases the rash is not seen upon the face; it is often 
faint npon the body, and may be present only upon certain parts ; when 
the rash is faint or scanty it is usually most marked in the groins and 
axillae, or over the buttocks and back of the thighs; it may last only 
one day, and sometimes may be so slight as to escape notice altogether. 
The eruption may be absent in some very mild cases, in certain others 
where the throat symptoms are severe, and in malignant cases. In the 
very severe cases many irregularities are seen, both as to the time of 
the appearance of the eruption and its character. Sometimes it occurs 
as large, irregular patches; again, it is macular, closely resembling the 
rash of measles. Xot infrequently an eruption of fine vesicles is seen, 
especially on the chest, axillae and abdomen. It is seen both in mild 
and severe cases. A well-developed bright rash indicates strong heart 
action, and a sudden recession of the rash is a sign of heart failure. 
Often a rash which is faint and doubtful in character may be brought 
out fully by a hot bath. 

With the eruption at its height, there is intense itching or burning 
of the skin, and in severe cases considerable swelling, chiefly noticeable 
upon the hands and face. 

Desquamation. — Shortly after the rash has faded, about the eighth 
day, there begins an exfoliation of the dead epidermis, known as des- 
quamation. This is even more characteristic of the disease than is the 
rash. It is usually first seen upon the neck and chest, where it appears 
as fine flakes. The desquamation of the trunk is completed in from 
one to three weeks. If baths and inunctions are being used, it may be 
scarcely perceptible. It continues longest where the epidermis is thick- 
est — viz., upon the hands and feet — and here it lasts from four to seven 
weeks, and not infrequently eight weeks. The appeara'nce of the fingers 
and toes during desquamation is characteristic. The finger tips usually 
peel first, and the new epidermis is pink and fresh-looking, while that 
which has not yet separated is of a dull gray color and loosened at the 
margin. Occasionally the epidermis of a considerable part of a finger 
may be loosened at once, so that a partial cast may be thrown off like 
the finger of a glove. Sometimes the patient comes under observation 
for the first time during desquamation, the history of the early symp- 
toms being doubtful or absent. Such desquamation as has been de- 
scribed, occurring both upon the hands and feet, may be regarded as 
conclusive evidence of scarlet fever. 

1. The Mild Cases. — The symptoms may be so slight as to be entirely 
overlooked, nothing being noticed until desquamation occurs. Usually, 
however, there is a rather abrupt invasion, with vomiting and a tem- 
perature from 100° to 103° F. The tonsils and pharynx arc congested, 
32 



958 



THE SPECIFIC INFECTIOUS DISEASES 



while the palate shows a punctate redness somewhat like the cutaneous 
eruption. The papillae of the tip and borders of the tongue are en- 
larged. Nearly always within twenty-four hours the rash makes its 
appearance, generally first upon the neck and chest. Very often it is 
not seen upon the face, but is abundant on the rest of the body. The 
rash fades on the third or fourth day, and has disappeared by the fifth 
day. There is very little prostration, the child often being with diffi- 
culty kept in bed. 

The highest temperature is coincident with the full eruption, and 
is usually seen during the first thirty-six hours of the disease. It grad- 
ually falls to normal by the third or fourth day. Some examples are 
shown in Fig. 152. In the mildest cases the temperature may never be 
above 100° F. 

Desquamation is often faint over the body, but is usually unmistak- 



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Fig. 152. — Mild Scarlet Fever. Three eases occurring successively in the sams family. 
Diagnosis not made until the third case developed, at which time the first one was 
found to be desquamating in a typical manner. 



able over the hands and feet, always being most marked where the 
eruption has been most intense. 

The mild cases are usually uncomplicated, but the possibility of otitis 
and of late nephritis should always be kept in mind, as these may occur 
even with the mildest attacks. The difficulties in diagnosis in mild 
attacks of scarlet fever are often great. It should be remembered that 
these cases are just as contagious as severe ones, and that from a mild 
attack a severe one is often contracted. It is frequently by these mild 
cases that this disease is spread in schools. In dispensaries, patients 
desquamating from scarlet fever are often seen who had been attending 
school regularly up to the time when they were brought for treatment 
for nephritis. 

2. Cases of Moderate Severity. — The onset is sudden with vomiting, 
which is usually repeated, rarely with convulsions. The temperature 
rises rapidly, and by the end of the first twenty-four hours has reached 
10 1° or 105° F. The rash generally appears within the first twenty- 



SCARLET FEVER 



959 



four hours, and its intensity is usually in direct proportion to the 
severity of the attack. Appearing first upon the neck or chest, it extends 
rapidly, covering the entire trunk and extremities, often in a few hours. 
It is generally typical in appearance, being made up of minute points, 
but giving the appearance of a uniform blush, which has been compared 
to a boiled lobster. Little change takes place in the rash for four or 
five days. After this it fades quite rapidly, and disappears by the sixtli 
or seventh day. 

The throat resembles that of the mild form, except that the redness 
is more intense and there is slight swelling of the tonsils, fauces, and 
uvula, and often pain upon swallowing. Occasionally small yellowish 
patches are seen upon the tonsils by the second or third day, but these 
can be wiped off and are not distinctly membranous. There is usually 
a moderate discharge 
of a sero-purulent 
character . from the 
nose. The lymph 
glands at the angle of 
the jaw are swollen 
and quite tender. The 
tongue may be coated 
in the center and show 
bright red points at its 
borders and tip, or it 
may be quite red and 
show everywhere the 
prominent papillae — the "strawberry tongue" ; while not exclusively seen 
in scarlatina, this is of considerable diagnostic value. It is rarely seen 
before the third day, and may continue several days or even weeks. 

During the height of the fever, restlessness, thirst, and, not infre- 
quently, slight delirium are seen. The temperature usually reaches the 
maximum by the second day, and falls gradually, but even in uncompli- 
cated cases the fever often lasts from ten to fourteen days (Fig. 153). 
The pulse in the early part of the disease is rapid, its frequency being usu- 
ally out of proportion to the height of the temperature. There is much 
prostration, frequently followed by quite a marked degree of anemia. 

This form of the disease rarely proves fatal apart from complica- 
tions. The complications seen most frequently in this form of scarlet 
fever are adenitis, otitis, and pneumonia. Nephritis is the only com- 
mon sequel. 

3. The Severe Cases. — The severe type of scarlet fever usually de- 
clares itself from the beginning. The incubation is short, and the full 
rash may be seen within a few hours after the initial symptoms. It is 



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Fig. 153. — Typical Temperature Curve of Uncom- 
plicated Scarlet Fever of Moderate Severity. 
Girl three years old. 



960 



THE SPECIFIC INFECTIOUS DISEASES 



usually intense and covers the entire body, even including the face. In 
other cases the eruption is delayed, often scanty, and may disappear in 
a few hours. The disease assumes one of two fairly distinct types; one 
is characterized by the severity of the general toxemia, the other by the 
predominance of the throat symptoms. In the first group the toxemia 
is shown by the height of the temperature, the severity of the nervous 
symptoms, and the profound cardiac depression. The temperature 
quickly rises often to 105° or 106° F., and usually remains steadily high 
until the death of the patient. The nervous symptoms are great pros- 
tration and delirium, which is sometimes active, but more often low and 
muttering. The pulse is very rapid, 160 to 180 being not uncommon; 
it is weak, compressible, often irregular, and the muscular sounds of the 
heart are feeble. The urine is scanty and almost invariably albuminous. 



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Fig. 154. — Typical Temperature Curve of Severe Scarlet Fever Ending in 
Recovery. Prolonged course due to severe throat symptoms lasting from second to 
sixth day, otherwise uncomplicated; boy twelve years old. 



Hemorrhages from the mouth, the nose, or other mucous membranes 
are occasionally seen. The duration of the disease in this form is gen- 
erally from five to seven days. Exceptionally the symptoms develop with 
greater intensity, and death follows in three or four days. A shorter 
duration than this, the so-called malignant scarlet fever, is rare. 

In the second group with predominant throat symptoms, the first 
three or four days may show nothing more than cases of the moderate 
type. Membranous patches appear upon the tonsils and spread to the 
soft palate, uvula, and pharynx, sometimes to the nose and through the 
Eustachian tube to the ear, very rarely involving the larynx. The mu- 
cous membrane of the mouth is intensely congested, and often partly 
covered by membrane; there are sordes on the lips and teeth, and there 
may be superficial ulcers, which bleed readily. The glands of the neck 
swell rapidly, often to a great size, and the cellular tissue about them 
is infiltrated. The head is thrown back to relieve the dyspnea which 
the pressure From this swelling occasions. There is an abundant dis- 



SCAELET FEVER 



961 



charge from the nose and mouth; the breath is very offensive. The 
general symptoms are those of a severe septicemia. The temperature 
is steadily high, usually between 103° and 105° F., for about a week, 
after which in cases ending in recovery it slowly falls unless com- 
plications develop (Figs. 154, 156, 157) ; but even in uncomplicated 
cases the fever sometimes continues for three weeks. In fatal cases the 
temperature may be -steadily high till death (Fig. 155), or it may fluc- 
tuate widely. The pulse is rapid, weak, and irregular. There is com- 
plete anorexia. There is low delirium or apathy, and sometimes all the 
symptoms of the typhoid condition are present. 

Signs of a bronchopneumonia may be found in the chest, and by 



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Fig. 155. — Severe Scarlet Fever, Septic Type; Death on Fourteenth Day. Intense 
angina; otitis; nephritis; necrotic inflammation of cervical lymph glands; girl seven 
years old ; death from heart failure. 



the end of the first week or early in the second, acute otitis often de- 
velops. The urine is rarely free from albumin, but the amount present 
is not usually great ; there may be hyaline and epithelial casts, and some- 
times blood. In some cases the throat symptoms predominate ; in others, 
those of general sepsis, but more frequently the two are combined and 
are directly proportionate to each other. In still other cases, instead 
of the membranous inflammation of the throat, it may be of a gan- 
grenous character, and extensive sloughing may take place in the pharynx 
or the cellular tissue of the neck, sometimes exposing or even opening the 
great vessels. 

The duration of the symptoms in cases with severe angina is from 
seven to fourteen days. There is increasing prostration and finally a 
septic stupor, with death from exhaustion, from heart failure, or from 
some complication — bronchopneumonia, pleurisy, nephritis, hemor- 
rhages following sloughing, pericarditis, or endocarditis. In cases which 



962 THE SPECIFIC INFECTIOUS DISEASES 

recover, the acute symptoms nearly always continue for a full month; 
and after escaping the dangers of sepsis and the early complications, 
the child has still to run the gauntlet of all the late complications — 
nephritis, pneumonia, endocarditis, pyemia, etc. A case may prove fatal 
as late as the end of the seventh week ; nearly all such results are due 
to nephritis or to its complications. 

4. Surgical Scarlet Fever. — The existence of a special form of scar- 
let fever occurring in patients with recent wounds or those who have 
been subjected to surgical operations, while stoutly maintained by sev- 
eral writers, has been vigorously denied by others. The question is one 
difficult of solution on account of the close similarity at times existing 
between the symptoms of scarlet fever and sepsis, and the necessity of 
deciding in an undoubted case whether the infection with scarlet fever 
was dependent upon or coincident with the wound. 

Hamilton, from a study of 174 reported cases, reached the conclusion 
that proof of the existence of a special form of scarlet fever rests upon 
the reports of cases, usually meager, and careful analysis of these would 
lead one to consider them rather as septic, than as scarlatinal infections ; 
that when there w r as undoubted evidence of scarlet fever, there was no 
proof that it was in any way due to the coincident wound, and that there 
is as yet no convincing proof in the literature that surgical scarlet fever 
is anything more than scarlet fever in the wounded. On the other hand, 
there have been observed clinically cases which seem to admit of no other 
reasonable explanation than that an abrasion of the skin, a recent 
wound, or even possibly a varicella vesicle, may be the point of entry 
of the scarlatinal infection, instead of the more usual portal, the 
pharynx. 

Relapses, Recurrences, and Second Attacks. — As a rule, one attack 
of scarlatina gives immunity through life. The exceptions are very few, 
but are well authenticated. We have seen but once an undoubted in- 
stance of a second attack in the same individual. 

Relapses or recurrences within a brief period after the first attack 
are more frequent. There are to be excluded the cases of pseudo-relapses 
in which the rash, having temporarily subsided for two or three days, 
reappears; also those where the rash varies in intensity from time to 
time; and, lastly, the cases in which, occurring late in the disease, it is 
due to septicemia or pyemia. They are comparable to the relapses of 
typhoid fever. They occur most frequently during desquamation, be- 
tween the seventh and twenty-fourth days. There may he not only 
a new eruption, but a rise of temperature, sore throat, and vomiting, just 
as in the initial attack. These recurrences are sometimes shorter and 
milder than the first attack, but this is by no mean's uniform, since 
Korner mentions eight cases where the second attack proved fatal. 



SCARLET FEVER 963 

In considering the subject of second attacks, the liability to errors in 
diagnosis must be borne in mind and only cases included which have pre- 
sented typical symptoms. 

Special Symptoms, Complications, and Sequelae. — Temperature.— 
The temperature curve of this disease is quite characteristic. There 
is usually seen an abrupt rise, the maximum being reached on the sec- 
ond day; there follows a period of variable duration, generally lasting, 
according to the severity of the case, from two to five days, in which the 
fluctuations are very narrow; then a gradual decline to normal, which 
is reached in the milder cases in about a week; in those which are more 
severe, in about two weeks. This typical curve (Figs. 151 and 152) is 
seen in the great proportion of uncomplicated cases which end in recov- 
ery. Deviations from it, therefore, are important as indicating that 
some complication exists. The explanation is usually to be found in the 
development of otitis, adenitis, nephritis, pneumonia, etc. Severe throat 
symptoms prolong the temperature but do not usually modify its course. 
In very severe cases ending fatally the high temperature is prolonged. 
In any case, a rise after the third day is unfavorable. 

Throat. — Three distinct forms of angina are seen in scarlatina : sim- 
ple or erythematous, membranous, and gangrenous. 

1. Erythematous Angina. — This can hardly be ranked as a com- 
plication, as it is nearly as constant as the scarlatinal rash. Usually 
there is only the intense general blush over the entire pharynx with 
the fine red points upon the hard palate; but there may be seen upon 
the tonsils grayish-yellow spots resembling those of follicular tonsil- 
litis, which can be wiped off, leaving a clean surface. This simple 
angina is at its height with the maximum temperature, and fades as 
the temperature falls. 

2. Membranous Angina. — These cases were formerly classed as scar- 
latinal diphtheria. Cultures, however, have shown that the great ma- 
jority of these inflammations are not true diphtheria, but are due to the 
streptococcus. 

The lesions of this form of angina are considered in the chapter on 
Membranous Tonsillitis. Usually on the second or third day of the 
disease an exudation appears upon the tonsils, and in the milder cases it 
covers only the tonsils. In the most severe form it may be seen within 
twnty-four hours of the onset, sometimes before the eruption appears. 
Beginning upon the tonsils, the membrane rapidly spreads to the entire 
pharynx, the mucous, membrane of the nose, the mouth, the Eustachian 
tube, and even to the middle ear. In eolor it may be gray, greenish, or 
almost black. The infiltration of the cellular tissue of the neck and 
the enlarged *lymph glands produce great external swelling, which may 
extend like a collar from ear to ear. The breath has a foul odor, the 



964 THE SPECIFIC INFECTIOUS DISEASES 

nasal discharge is thin and fetid, and nasal respiration is obstructed, so 
that the mouth is open constantly. It is surprising that the larynx is 
so seldom invaded. 

These local changes are accompanied by constitutional symptoms of 
great severity, which are due to a general streptococcus septicemia; 
bronchopneumonia and nephritis are very frequent, otitis is almost con- 
stant, and suppuration of the lymphatic glands is not uncommon. The 
eruption is often irregular and late in appearing. 

The frequency with which diphtheria coexists with scarlatina varies 
greatly. In hospital practice the proportion often runs as high as thirty 
or forty per cent. In private practice it is much lower. The strepto- 
coccus angina is usually seen at the height of the disease; true diphtheria 
may occur at any time, even during convalescence. The only positive 
means of differentiation is by cultures, which should invariably be made 
from the throat of every patient admitted to a scarlet-fever hospital, and 
of every case in private practice showing any exudate upon the tonsils. 

3. Gangrenous Angina. — This is seen only in. the worst cases of scar- 
let fever. The process may be gangrenous from the outset, or preceded 
by a membranous inflammation. It is sometimes insidious in its de- 
velopment. There is a fetid odor to the breath, an irritating discharge 
from the nose and mouth, with very great glandular swelling. The ton- 
sils are gray or grayish-black in color, and large masses of necrotic 
tissue may be removed with the forceps from the tonsils, uvula, fauces, 
or pharynx, and sometimes sloughing occurs in the cellular tissue of the 
neck. Blood-vessels of considerable size are sometimes opened, and 
serious or even fatal hemorrhage may result. The constitutional symp- 
toms are those of great asthenia, prostration, and profound cachexia, 
followed almost invariably by a fatal termination. 

Lymph Nodes. — These are swollen in all cases accompanied by severe 
angina. The inflammation may be simply an acute hyperplasia, or it 
may go on to suppuration and necrosis. Abscess does not often occur 
at the height of the disease, but the early swelling may almost completely 
subside only to recur, and suppuration may take place even as late 
as the fifth or six week of the disease. It may be confined to the 
glands or be complicated by suppuration in the cellular tissue of the 
neck. 

Cellulitis of the Neck. — This usually occurs toward the end of the 
first week, and is associated with grave throat symptoms. Rapid and 
extensive infiltration occurs, the skin becomes tense and brawny, the 
head is held back, and there may be considerable dyspnea. The infil- 
tration may be only in the neighborhood of the lymph glands or it 
may be diffuse. Unless relieved by early incision, the diffuse form may 
result in suppuration and extensive sloughing, which may be deep 



SCAELET FEVER 



965 



enough to lay bare the large vessels of the neck. This is a complication 
of the gravest possible import. Death may occur from septicemia be- 
fore or after sloughing or from hemorrhage due to opening by ulcera- 
tion of the external carotid or some of its branches; or there may be 
associated thrombosis of the jugular vein, leading to thrombosis of the 
lateral sinus, meningitis, or pyemia. 

Ears. — The otitis is due to direct extension of the infection from 
the rhinopharynx. It is the most frequent complication of scarlatina, 
and in doubtful cases may have some diagnostic importance. As a rule, 
the younger the child the greater the liability to otitis. It is more fre- 
quent in winter than at other seasons, and is closely connected with the 
severity of the throat symptoms. Of 4,397 cases reported by Finlayson, 



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Fig. 156. — Severe Scarlet Fever; Otitis; Mastoiditis; Death. Typical symptoms 
and temperature curve until fourteenth day; secondary rise of temperature from 
otitis; double paracentesis on the fifteenth day; mastoid operation on the sixteenth 
day; death twelve hours later from septicemia; boy five years old. 



otitis occurred in 10 per cent, and of 1,008 cases reported by Caiger, 
in 13 per cent. In Burkhardt's statistics the proportion was as high 
as 33 per cent. Of cases accompanied by severe throat symptoms otitis 
is present in fully 75 per cent. 

As a rule, both ears are affected. Otitis is most frequent early in the 
second week, but may occur at any time, even during convalescence. 
When it develops at the height of the disease there are in some cases 
no new symptoms; in others there is pain and deafness and a rise in 
the temperature, which may fall after paracentesis or rupture of the 
drum membrane, or there may be extension to the mastoid (Fig. 156). 
The otitis is often overlooked unless the ears are regularly examined. 
The form of inflammation may be catarrhal or purulent, the latter being 
often accompanied by necrotic changes. 

Be/old mak°a the following report upon 185 cases showing the dis- 



906 



THE SPECIFIC INFECTIOUS DISEASES 



astrous consequences of scarlatinal otitis: "In 30 there was entire 
destruction of the membrana tympani; in 59 the perforation comprised 
two-thirds or more of the membrane; in 15 there was total loss of hear- 
ing on one side, and in 6 of the cases upon both sides; in 77 of the cases 
the hearing distance for low voice was less than twenty inches." 

As a cause of permanent deafness and deaf-mutism, no disease of 
childhood compares in importance with scarlet fever. May has collected 
statistics of 5,613 deaf-mutes, of whom 532 owed their condition to 
otitis following scarlet fever. 

Kidneys. — Albuminuria accompanies nearly all the severe cases of 
scarlet fever. In many this is simply the ordinary febrile albuminuria 
due to acute degeneration of the kidneys. In those with severe throat 
complications, and in nearly all the septic cases, there is an aGute diffuse 
nephritis; the interstitial changes may be very marked and the kidneys 



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Fig. 157.-Scarlet Fever or Moderate Severity Followed by Fatal Nephritis. 
Early symptoms typical and uncomplicated; twenty-first day vomiting; twenty-fifth 
day uremic convulsions; death twenty-sixth day. No dropsy; urine never below 
10 ounces in twenty-four hours; girl ten years old. 



contain minute abscesses. This occurs at the height of the febrile 
process and is rarely accompanied by dropsy; but albumin, casts, and 
even blood may be found in the urine. The most severe and the most 
characteristic renal complication, and that generally designated as 
postscarlatinal nephritis, is a diffuse nephritis, with changes in the 
glomeruli as the most striking feature. It usually develops during the 
third or fourth week of the disease, and may follow mild as well as 
severe cases (Fig. 157). The onset may be gradual, with dropsy and 
urinary changes, usually accompanied by a slight rise of temperature; 
or it may be abrupt, without dropsy but with convulsions, suppression 
of urine, and very high temperature. 

The characteristic urine is of a reddish or smoky color and scanty. 
It contains a large amount of albumen, often sufficient to render the 
urine solid upon boiling. Under the microscope there are seen red 
Uoo<l-<<>lls, pus colls, epithelial cells, and casts of every variety. Death 
may take place from acute uremia, or the attack may be followed bv 



SCARLET FEVER 967 

permanent damage to the kidneys. It is more fully described with the 
Diseases of the Kidney. 

Joints. — Acute articular rheumatism may occur coincidently with 
the development of the scarlatinal rash, and occasionally during con- 
valescence in patients who have a predisposition to that disease. Acute 
swelling of the joints is sometimes of pyemic origin. In pyemic ar- 
thritis the large joints are usually involved and the lesions are apt to 
be multiple. Joint disease may occur as a sequel of scarlet fever, 
when it is secondary to disease of the bone or to periarticular abscesses 
opening into the joint. 

The foregoing include but a small proportion of the joint complica- 
tions seen in scarlet fever. The most frequent and most characteristic 
form of inflammation is scarlatinal synovitis, often improperly called 
scarlatinal rheumatism. It occurs in different epidemics with varying 
frequency. Carslaw (Glasgow), in 533 cases of scarlet fever, met with 
synovitis in 60 patients. It is seldom seen in children under three years 
of age, and is most frequent after five years. It may occur in mild as 
well as in severe cases. According to Ashby, synovitis develops toward 
the end of the first or the beginning of the second week. The symptoms 
are generally mild, and are followed by prompt recovery. Suppuration 
is rare. Any of the joints may be attacked, but those of the wrist, hand, 
elbow, or knee are most frequently affected. The symptoms are redness, 
moderate pain, swelling, which is usually due to synovial distention, and 
sometimes a slight rise in temperature. The duration is generally but 
three or four days, and in most cases there is spontaneous recovery. Be- 
sides these milder cases there occurs a much more severe form, which 
may develop later, even during convalescence. It is not very acute, but 
is accompanied by fever, and both the fever and swelling may continue 
for many weeks. Recovery may be complete or some joint disability 
may remain and chronic arthritis may follow. 

Lungs. — The pulmonary complications of scarlet fever are neither 
so frequent nor so important as those of measles. Bronchopneumonia 
is usually found at autopsy in septic cases where death has occurred 
later than the third or fourth day, but it is not generally recognizable 
so early by physical signs. 

Tn septic cases pleuropneumonia sometimes occurs early in the 
disease and at otber times late, generally associated with nephritis, but 
occasionally without it. Jt is not infrequently a direct cause of death. 
Empyema may follow pleuropneumonia or occur with pyemia or neph- 
ritis, but with the latter, simple serous pleurisy is more common. 
Edema of the lungs occurs chiefly with nephritis, in which it is the 
most common cause of death. 

Heart. — Cardiac murmurs arc frequent at the height of the disease; 



968 THE SPECIFIC INFECTIOUS DISEASES 

in fact they are heard in almost all severe cases. Endocarditis and peri- 
carditis are oftenest seen in septic cases, and with post-scarlatinal neph- 
ritis. Endocarditis may be simple or malignant, and may lead to em- 
bolism during convalescence. Some degenerative changes in the cardiac 
muscle are probably present in all the severe cases. Acute dilatation 
may result, which is sometimes a cause of death. 

Blood. — In all cases there is a rapidly progressing anemia that lasts 
into convalescence. The reduction in the red cells in an average case is 
about one million. The chief interest, however, attaches to the number 
and character of the white cells. In mild cases there may be only a 
moderate increase in their number, usually to from 10,000 to 14,000. 
It is in cases of moderate severity that the characteristic changes are 
found. In these there is a decided leucocytosis which appears early, 
attains its maximum about the fourth day, and gradually declines until 
the normal is reached, which may not be until the third, fourth, or fifth 
week. The maximum is usually about 30,000 to 35,000 ; although it may 
be as high as 75,000. During the first week the polymorphonuclear 
neutrophiles form from 90 to 95 per cent of these cells; the eosinophiles 
as well as the lymphocytes are diminished. After the fifth or sixth day, 
there is a rapid increase in the eosinophiles which attain their maximum 
— sometimes 20 per cent of the total leucocytes — between the fourteenth 
and twenty-first days. After the third week they gradually diminish. 
Exceptionally there is found in convalescence a relative lymphocytosis, 
which may lie as high as 50 per cent. Complications, nephritis excepted, 
usually cause actual as well as relative increase in the polymorphonuclear 
neutrophiles. In malignant and rapidly fatal cases there is usually a 
very small proportion of eosinophiles, and little if any leucocytosis, 
though exceptionally it may be high. Much has recently been written 
regarding the so-called "inclusion bodies" which are found in the leu- 
cocytes in this disease. It seems clear that they are not specific and 
that their presence is not diagnostic of scarlet fever. They are regu- 
larly found in all but the mildest cases before the fourth day; but they 
are found also in other conditions, e. g., pneumonia, sepsis and ery- 
sipelas. 

Digestive System. — Functional disturbances are very frequent, and, 
in fact, are seen in most of the cases, but organic changes are rare. 
Vomiting is the mode of onset in the majority of cases, but rarely con- 
tinues throughout the attack. Diarrhea may be associated with it un- 
der both conditions. The tongue is nearly always coated, and clears off 
in quite a characteristic way, which, with the prominent papillae, gives 
rise to the "strawberry" appearance. Catarrhal stomatitis is a very 
Prequenl complication, and in many cases of severe membranous angina 
the same process is seen in the buccal cavity. 






SCARLET FEVER 969 

Nervous System. — Nervous complications and sequelae are seen less 
frequently with scarlatina than with most of the infectious diseases of 
such severity. Convulsions are frequent at the outset, and generally 
indicate a severe attack, though not invariably so. Occurring late in 
the disease, they are usually due to uremia. Meningitis may occur as 
a complication of otitis, in pyemic cases, and sometimes with post- 
scarlatinal nephritis. Paralysis from peripheral neuritis is rarely seen. 
Hemiplegia sometimes occurs from meningeal hemorrhage, or from em- 
bolism secondary to endocarditis and associated with nephritis. Chorea 
was noted as a sequel in only three of 533 cases reported by Carslaw. In 
a report of 187 cases of epilepsy, Wildermuth states that it followed 
scarlet fever in 12 cases. Insanity has been occasionally observed, the 
usual form being acute mania, with complete recovery in a few weeks or 
months. 

Gangrene. — Cases of symmetrical gangrene after scarlet fever have 
been reported. The parts generally affected are the buttocks, thighs, 
and arms, but it may occur almost anywhere. The pathology of these 
cases is obscure. The process usually begins in several places simul- 
taneously, or in rapid succession, and advances steadily till death 
occurs. 

Other Infectious Diseases. — Diphtheria is most frequently seen, and 
may be present even when there is no distinct membrane. 

Scarlatina may also be complicated by measles, varicella, or facial 
erysipelas, and occasionally by variola or typhoid fever. The symptoms 
are often an irregular commingling of those belonging to the two 
diseases. They may begin simultaneously, or more frequently one de- 
velops as the other is subsiding. 

Diagnosis. — The characteristic symptoms of scarlet fever are the 
abrupt onset, usually with vomiting, the marked elevation of tempera- 
ture, the erythematous condition of the throat, the punctate eruption on 
the hard palate, with the appearance of the rash within twenty-four 
hours, and later the characteristic appearance of the tongue. The diffi- 
culties of diagnosis usually depend upon irregularities in the eruption. 
The variations are seen in the mildest and in the most severe cases. 
In the former the rash may be of short duration, often less than a day, 
and in consequence easily overlooked ; or it may be present only upon 
certain parts of the body instead of being diffuse. In every doubtful 
case the groins, axillae, and loins should be closely scrutinized for a punc- 
tate eruption. In very severe attacks the rash may appear late or recede 
after being fully out, or it may be hemorrhagic or in irregular blotches. 
In any case, too much stress should not be placed upon the rash alone. 

Until we have some exact means of laboratory diagnosis as in 
typhoid fever, malaria, and diphtheria, an absolute diagnosis will in 



070 THE SPECIFIC INFECTIOUS DISEASES 

certain cases be impossible. Sometimes the diagnosis remains doubtful 
until the end, although occasionally confirmatory evidence may be ob- 
tained even in convalescence. Thus, a patient may desquamate in a 
manner so typical as to leave no doubt as to the nature of the preceding 
illness; again, the occurrence of a characteristic sequel, such as nephritis 
in the third or fourth week, may testify strongly for scarlatina as the 
primary disease; and, finally, the outbreak of undoubted cases among 
children who have been in contact with the patient is practically con- 
clusive, always provided other sources of infection can be excluded. 
Desquamation, however, follows so many other eruptions that when 
slight or irregular, one should not rely upon it as an evidence of scarlet 
fever, but only upon a typical exfoliation upon the hands and feet. It 
is a point of some practical importance not to oil the skin of a patient 
when awaiting desquamation for diagnosis, as this alters very much the 
characteristic appearances. In some puzzling epidemics the length of 
the incubation may be of material assistance in the diagnosis; when 
this is regularly more than a week, one may be pretty sure that he is 
not dealing with scarlet fever. 

Scarlet fever with severe throat symptoms and doubtful eruption 
can be distinguished from diphtheria only by cultures. Measles is 
distinguished by the length of the invasion, the catarrhal symptoms, 
and the slowly spreading eruption, but most of all by Koplik's spots. 
Much more difficult is it to distinguish between mild scarlatina and 
rubella. In rubella the important thing is that, although the rash may 
be well marked, often covering the body, the constitutional symptoms 
are few or entirely absent. In scarlet fever with an eruption of the 
same intensity there is almost invariably a considerable elevation of 
temperature, usually 102° or 103° F., and a bright-red throat. 

There are so many skin eruptions which may resemble that of scarlet 
fever, that it is always hazardous to make the diagnosis of this disease 
from the eruption alone. This is especially true of sporadic cases 
occurring in infants; there is seen at this age a great variety of erup- 
tions, usually associated with digestive disturbances, which closely simu- 
late a scarlatinal rash; but most of them are of short duration. A 
scarlatiniform erythema is occasionally seen after diphtheria antitoxin, 
also in influenza, typhoid fever, pneumonia, and varicella, which may 
cause them to be mistaken for scarlet fever, or may lead to the con- 
clusion that both diseases are present. The same is the case with the 
septic erythema occurring in surgical patients. Belladonna, quinin, 
and occasionally antipyrin, the salicylates and aspirin may produce 
eruptions more or less closely resembling that of scarlet fever. This 
is also true of some cases of urticaria and other forms of skin disease. 
Eruptions resembling scarlet fever may also arise from irritation due 



SCARLET FEVER 971 

to clothing, to heat, to the local application of irritants to the chest, 
such as camphorated oil, etc. There is little doubt that many of the 
cases reported as relapsing scarlatina are really examples of recurring 
erythema, particularly as some of the latter are followed by a desquama- 
tion which is very similar to that after scarlatina. 

Prognosis. — There is no disease in which it is more difficult to fore- 
tell the outcome than in scarlet fever. Cases apparently of the mildest 
type not infrequently develop serious symptoms and even complications 
that could not be foreseen. Symptoms indicating a bad prognosis are, 
very high temperature, especially one which continues to rise for the 
first three or four days, and severe nervous and throat symptoms. The 
most common cause of death is the disease itself, the scarlatinal toxemia. 
From this cause more than half the deaths occur. Next are the com- 
plications, cardiac, pulmonary, renal, otitic, mastoid and cerebral, given 
in the order of their frequency. The mortality of scarlet fever varies 
much in different epidemics. In some, nearly all the cases are of a 
mild type, and the mortality may be as low as 3 or 4 per cent; in 
others, a severe or malignant type prevails, and it may be as high as 
40 per cent. The disease is, as a rule, more fatal in the youngest 
infants, becoming less so as age advances. 

The following are the mortality records from various European 
sources : 

Ashby, Manchester Hospital 681 cases; mortality, 12.2 per cent. 

Koren, a single epidemic 426 " " 14.0 " " 

Bendz, Copenhagen 22,036 " " 12.2 " " 

Ollivier, three Paris hospitals for five years. . 893 " " 14.0 " " 

Fleischmann, five epidemics 1,356 " " 10.0 " " 

The general mortality of the disease may therefore be assumed to be 
from 12 to 14 per cent; it is, however, much higher than this among 
young children, as shown by the following figures: 

New York Infant Asylum 116 cases under 5 years; mortality, 20 per cent. 

Ashby, Manchester Hospital 259 " " 5 " " 23 " " 

Bendz not stated " 5 " " 13 " " 

Heubner 136 cases " 7 " " 30 " " 

Fleischmann not stated " 4 " " 43 " " 

. Under five years of age the average mortality from scarlet fever is, 
therefore, between 20 and 30 per cent. 

Prophylaxis. — Even the mildest cases should be isolated for four 
weeks. If complications exist, such as otitis, rhinitis, pharyngitis, em- 
pyema, or suppurating glands, the quarantine should be continued until 
these conditions are cured. Patients should not .be allowed to mingle 
with other children for at least a month after all symptoms have sub- 



072 THE SPECIFIC INFECTIOUS DISEASES 

sided, and should be forbidden to sleep with other children for three 
months. Children in the family who have not been exposed to the 
disease should be immediately sent away; and those who have been 
exposed, separately quarantined for at least a week. 

After recovery, the patient, before he is released from quarantine, 
should have one thorough bath, the entire body, including the hair and 
scalp, being scrubbed with soap and water, and every particle of cloth- 
ing changed. 

The nurse should be quarantined with the patient, and should not 
mingle with other members of the family until a complete change of 
clothing has been made and hands and face thoroughly washed. The 
nurse and all others in close contact with a severe case should use fre- 
quently an antiseptic gargle and a nasal spray. The care of the room 
during and after the attack has been considered in the introductory 
pages of this Section. 

Schools are hot-beds for the spread of scarlet fever. The greatest 
sources of danger are the mild or walking cases in which the disease has 
not been recognized, and the clothing of patients who have had a severe 
form of the disease. As a rule, a child should be kept from school six 
weeks from the beginning of the attack, and the certificate of a physician 
should be required before readmission. Other children in the house- 
hold should not be allowed to attend schools of any kind during the 
period of active symptoms; they should be kept at home on the average 
for a month. This precaution is necessary, first, because they might 
carry the disease from the patient at home ; secondly, because otherwise 
they might themselves attend school while suffering from the disease 
in a very mild form or during the period of invasion. When the sick 
child is completely isolated, the danger from the first source is very 
slight. During severe epidemics it frequently becomes necessary to 
close all schools. 

In general, it is to be remembered that the danger is first from 
the patient, secondly from the room, and thirdly from the nurse. Spe- 
cial attention should always be given to the complete and immediate 
isolation of the first case which appears in an institution or community, 
which should apply to mild as well as severe forms of the disease. 

Treatment. — There is as yet no specific for scarlet fever. The physi- 
cian's duty in the average case consists in (1) establishing proper quar- 
antine and the carrying out of adequate means of disinfection; (2) 
the hygienic care of the patient; (3) directing the diet; (4) watching 
for complications, especially otitis and nephritis. It should be borne 
in mind that otitis is rarely accompanied by pain or tenderness, and is 
recognized only by aia examination of the ears; also that severe and 
fatal nephritis may follow mild as well as severe cases. 



SCARLET FEVER 973 

Mild attacks require no medicine. Children should be kept in bed at 
least a week after the fever has subsided, and upon a diet chiefly of milk 
and farinaceous food with plenty of water for a period of three weeks. 
This is an important matter in the prevention of nephritis. During 
the height of the eruption, the intense itching of the skin may be allayed 
by sponging with a bicarbonate of soda solution, or by inunctions with 
vaseline, or by the free use of rice or talcum powder. Plenty of fresh 
air should always be secured in the sick-room. As soon as the fever 
and rash have disappeared, daily warm baths with soap and water should 
be used, after which the entire body should be anointed with vaseline, 
with the purpose of facilitating desquamation. 

The temperature does not usually require interference when it only 
occasionally rises to 104° or 104.5° F. But if there is hyperpyrexia, or 
a temperature which ranges from 104° to 105.5° F. or over, antipyretic 
measures are called for. Hydrotherapy is much safer and more certain 
than drugs. Sometimes sponging is sufficient, but in the great propor- 
tion of cases the pack or bath is required. The use of water in the 
reduction of temperature is especially indicated in septic cases with 
typhoid symptoms, and in those with pronounced cerebral symptoms. 
The temperature of the water employed will depend upon the duration 
of its application. It is generally better to use prolonged sponging or 
bathing with tepid water than water at a lower temperature for a 
shorter period. 

The nervous symptoms are frequently better controlled by ice to the 
head and by cold sponging than by medication. Antipyretic . drugs may 
occasionally be useful to control restlessness and promote sleep, and in 
mild cases to effect a moderate reduction in temperature. Phenacetin is 
usually to be preferred. 

As soon as the pulse becomes weak or rapid and irregular, or the 
first sound of the heart feeble, stimulants should be given, no matter at 
what stage of the disease. In septic, or malignant cases, or in those 
accompanied by severe angina, adenitis, or cellulitis, stimulants should 
be used freely. Digitalis is especially valuable when the pulse is weak 
and the tension low. It may be given alone or combined with caffein; 
one minim of the fluid extract of digitalis, and gr. ^ of caffein being 
the initial doses for a child of five years. 

The erythematous sore throat requires no treatment except the use 
of a bland gargle. If there is a profuse nasal discharge, gentle nasal 
syringing with a warm saline or boric-acid solution may be used with 
the hope of preventing infection of the middle ear. The local treatment 
of the throat is the same as that of other cases of severe angina. 

Milder forms of adenitis require no local treatment. When severe, 
the glands should be covered with ichthyol, and an ice-bag applied 



974 THE SPECIFIC INFECTIOUS DISEASES 

continuously. Poulticing almost invariably does harm. If an abscess 
forms, early incision should be made. 

The ears of patients with severe throat symptoms should be examined 
daily in order that there may be no delay in performing paracentesis 
should this become necessary. Any unusual rise in temperature should 
direct attention to the ears. The indications for the operation are the 
same as in other severe forms of otitis. 

The physician should be constantly on the watch for the develop- 
ment of nephritis, not only during the febrile period, but also during 
convalescence. Eepeated examinations of the urine are absolutely 
necessary. These are facilitated by having a rack of test tubes and 
the ordinary reagents for detecting albumin in the sick-room, so that 
the physician may himself examine daily a fresh specimen of urine. 
The nurse should be instructed to measure and record accurately 
the twenty-four hours' urine throughout the attack. The treatment 
of scarlatinal nephritis has been considered in the chapter devoted to 
Diseases of the Kidney. Diffuse cellulitis of the neck calls for free, 
early incision as the only means of preventing extensive sloughing. 

On the assumption that streptococci, though not the cause of the 
disease, are still responsible for most of the serious complications of 
scarlet fever, sera prepared by means of several different strains of this 
organism have been produced and extensively used but without any uni- 
form or striking success. One has been produced by Moser (Vienna), 
concerning whose effects there is much more favorable evidence. Escher- 
ich, Bokay, and other reliable Continental observers in their reports have 
declared that its effects are not less striking than those obtained from 
diphtheria antitoxin. It must be given in very large doses, from 100 to 
200 c. c. The value of streptococcus serum has not yet been demon- 
strated in this country. 

Transfusion and the intramuscular injection of blood or of blood 
scrum from patients convalescent from scarlet fever have been em- 
ployed by Zingher (New York) and others in very severe forms of 
scarlatinal toxemia. The beneficial results which have followed have in 
some instances been so striking that they can hardly be considered acci- 
dental. In desperate cases this should be tried whenever practicable. 
Considerable amounts of blood must be used, from 100 to 300 c. c, 
according to the age of the patient. Some benefit also under similar 
conditions seems to follow the injection of normal blood from healthy 
persons. 

During convalescence, the urine should be frequently examined. 
Antisepl ic gargles and a nasal spray should be used as long as a purulent 
discharge from the nose or pharynx continues. 



MEASLES 975 

"CHAPTER II 
MEASLES 

(Rubeola, Morbilti) 

Measles is an epidemic contagious disease, more widely prevalent 
than any other eruptive fever; very few persons reach adult life with- 
out contracting it. One attack usually confers immunity. It is highly 
contagious even from the beginning of the invasion, and spreads with 
great rapidity from the patient to all susceptible persons exposed. The 
infectious agent, however, does not cling to clothing or apartments 
as does that of scarlet fever. Measles has a usual incubation period of 
from eleven to fourteen days; a gradual invasion of three or four days 
with symptoms of an acute coryza, and a maculopapular eruption which 
appears first upon the face and spreads slowly over the body, and which 
lasts from four to six days. This is followed by a fine bran-like des- 
quamation, which is complete in about a week. The mortality is low, 
except among infants and delicate children, in whom it may reach 30 
or even 40 per cent. In institutions for infants and young children 
no epidemic disease is more to be dreaded than measles, not only on 
account of its severity, but from the frequency with which, in such sub- 
jects, it is complicated by bronchopneumonia. 

Etiology. — Little is as yet known of the essential cause of measles. 
Anderson and Goldberger, and since them a number of others, have 
succeeded in inoculating monkeys with the blood and also with the nasal 
and buccal secretions from patients with measles and have produced a 
disease attended by fever, eruption and respiratory symptoms which 
are believed to be identical with measles in the human subject. They 
have successfully carried the strain of infection by blood inoculations 
through six generations of monkeys. The virus obtained by Anderson 
and Goldberger passes through the Berkfeld filter, resists drying and 
freezing for twenty-four hours, but is destroyed by a temperature of 
55° C. Blood from patients with measles was found to be infective at 
least twenty-four hours before the eruption and for twenty-four hours 
after its appearance. Later than this its infectivity is much lessened 
and soon disappears. The secretions from the mouth and nose were 
infective for the monkey only when collected during the stage of erup- 
tion. The experiments suggest a rapid loss of infectivity with the 
beginning of convalescence. Attempts to convey the disease to animals 
by inoculating with scales from desquamating patients were unsuc- 
cessful. 



076 THE SPECIFIC INFECTIOUS DISEASES 

Clinical observations indicate that the virus of measles is more read- 
ily diffused than that of most communicable diseases ; also that its viabil- 
ity is less than most pathogenic organisms. Only a short exposure is 
required to communicate the disease. 

Predisposition. — Infants under six months do not readily contract 
measles, but all other children are extremely susceptible. In an epidemic 
reported by Smith and Dabney, 110 unprotected children, between the 
ages of eight and eighteen years, were exposed and only two escaped. 
In one institution epidemic observed by us there were 62 children over 
two years of age ; five were protected by a previous attack and escaped ; 
of the remaining 57 children, 55 took the disease. There were also in 
the institution 113 children under two years old; of this number 78 
per cent took the disease; but, although a number were exposed, not 
one child under six months old contracted measles. We have, however, 
seen in one instance a typical attack of measles in an infant of seven 
months, the disease having been contracted in this case from the mother. 
The age of the persons affected depends much upon the length of time 
since the last outbreak of the disease. In an epidemic occurring in the 
Island of Guernsey, where the disease had not prevailed for many years, 
all ages were affected, the youngest being twelve days old, and the oldest, 
a man and wife, each aged eighty years. Instances have been reported 
by Somer, Gautier and others in which the eruption of measles has either 
been present at birth or has developed within a few hours after birth, 
when the mother was suffering from the disease at the time. 

Except, then, in early infancy, the probabilities are very strong that 
every child exposed to measles will contract the disease. Occasionally, 
however, one is seen who seems insusceptible, no matter how close the 
exposure. 

Epidemics of measles are more frequent and more severe during the 
winter and spring months. They are least frequent and mildest during 
the summer and autumn months. 

Incubation. — In 144 cases, 1 in which the period of incubation could 
be definitely traced, it was as follows : 

Incubation of less than nine days 3 cases. 

" nine or ten days 22 " 

" eleven to fourteen days 95 " 

" fifteen to seventeen days 19 " 

" eighteen to twenty-two days 5 " 

Tims m 66 per cent of the cases the incubation was between eleven and 
fourteen days, and in only one case was it less than a week. The con- 

1 About twenty-five of these are taken from our own records; the remainder 
are mainly isolated cases, scattered through medical literature. The incubation 
i n ckoned from the time of exposure to the beginning of catarrhal symptoms. 



MEASLES 977 

stancy of the incubation period is strikingly shown in some epidemics. 
Thus in the one reported by Smith and Dabney in an institution in 
Virginia, exactly eleven days after the rash appeared in the first case, 
the disease developed in twenty children — no cases having occurred in 
the interval. 

Duration of the Infective Period. — This is much shorter than in scar- 
let fever, and the average duration may be placed at two and a half 
weeks. The minimum period of isolation should be ten days after 
the appearance of the eruption. It should be extended if there persist 
discharges from the nose and throat or a cough. Haig-Brown discharged 
fifty-eight cases on or before the twenty-ninth day of the disease, and 
in no instance was measles spread by these children. Ransom, however, 
records one instance in which it was communicated thirty-one days after 
the appearance of the rash. 

Measles is highly contagious from the very beginnings of the catarrhal 
symptoms. A case occurred under our observation in which a child 
conveyed the disease four days before the rash appeared; and many 
such have been observed. An instance is known to us where, of thirteen 
little girls at a children's party, only one (protected by a previous 
attack) escaped measles; the source of infection was a child who showed 
no rash until the following day. The period during which the disease 
is most contagious is still a matter of dispute, the general belief being 
that it is coincident with the most severe catarrhal symptoms and the 
beginning of the eruption. 

With the fading of the eruption and the subsidence of the catarrh, the 
communicability of measles diminishes rapidly. It is generally pro- 
portionate to the severity of the catarrhal symptoms, and when these 
are protracted it is probable that the disease may be communicated for 
a much longer period than in the usual case. 

Mode of Infection. — Measles is usually spread by direct exposure 
to an affected person. The infectious agent is chiefly disseminated by 
the minute droplets which are given off during coughing and sneezing, 
probably also by the discharges from any affected mucous membrane. 
Proximity to a patient seems necessary to contagion, but not actual con- 
tact. Infection from the scales during desquamation probably does not 
occur. It is very infrequent that measles is conveyed through the 
medium of clothing, furniture, or a third person. Though a good many 
instances are on record in which the disease has been carried by a third 
person, this, after all, very rarely happens and we think never unless the 
contact both with the sick and the well child is very close and the interval 
short. 

Lesions. — The only constant lesions of measles are those of the skin 
and the mucous membranes, chiefly of the respiratory tract. According 



978 THE SPECIFIC INFECTIOUS DISEASES 

to Neumann, the process in the skin is of an inflammatory character, 
but is more superficial than in scarlet fever. There is congestion, accom- 
panied by an exudation of round cells about the small blood-vessels, and 
also about the sweat and sebaceous glands, and the papillae. To this 
exudation and the edema, the swelling of the skin is due. It occurs 
everywhere, but is especially noticeable upon the face. 

The changes in the mucous membranes are quite as much a part of 
the disease as are those of the skin. There is a catarrhal inflammation 
affecting the conjunctivae, nose, pharynx, larynx, trachea, and large 
bronchi, which varies in intensity with the severity of the attack. In the 
most severe forms in infants and in young children, this inflammation 
extends with great uniformity to the small bronchi, and usually to the 
air vesicles, causing bronchopneumonia. In severe cases, the lesion in 
the pharynx and larynx also, instead of being catarrhal, may be mem- 
branous ; the larynx being much more frequently involved, and the ears 
much less so, than in scarlet fever. Freeman has described areas of focal 
necrosis in the liver similar to those found in diphtheria; they were 
present in four of twelve cases examined. The lesions of the lungs and 
of other organs will be more fully considered under the heading of 
Complications. 

The bacteria which are associated with the lesions of the respiratory 
tract are the staphylococcus and the streptococcus, separately or together, 
and either form may be associated with the pneumococcus (see Bac- 
teriology of Bronchopneumonia). Measles produces conditions in the 
mucous membranes of the respiratory tract which are especially favor- 
able for the development of these bacteria. They are present in the 
mouth in great numbers; they may cause pneumonia, otitis, and other 
local inflammations, and the pneumococcus or streptococcus may produce 
a general septicemia. 

Symptoms. — Invasion. — As a rule, the invasion of measles is gradual, 
both the fever and catarrhal symptoms increasing steadily up to the 
appearance of the eruption. The characteristic symptoms of the inva- 
sion are those of a severe coryza — suffusion of the eyes, increased lachry- 
mation, photophobia, sneezing, and a discharge from the nose. The 
hoarse, hard cough indicates that the catarrhal process has involved 
the larynx and trachea, as well as the visible mucous membranes. Fre- 
quently the patient complains of some soreness of the throat, and on 
inspection there is seen moderate congestion of the tonsils, fauces, and 
pharynx. On the hard palate are frequently seen small red spots. 
Much more characteristic are the minute white spots upon the mucous 
membrane of the cheeks, known as Koplik's sign (see Diagnosis). The 
constitutional symptoms are indefinite, and may be met with in almost 
any disease. These are dulness, headache, pains in the back, and the 



MEASLES 



979 



usual symptoms of malaise; there is rarely vomiting or diarrhea. Drow- 
siness is a frequent symptom, and is regarded by the laity as charac- 
teristic. 

The exceptional cases in which the invasion is abrupt are puzzling. 
There may be a sudden accession of fever with vomiting, and even con- 
vulsions, as in a case lately under our observation. Xot infrequently, 
when the disease prevails epidemical]}', the invasion is sudden, with high 
fever and pulmonary symptoms which are so severe as to mask every- 
thing else until the rash makes its appearance, the case up to that time 
being often regarded as one of primary pneumonia or of grippe. The 
duration of the stage of invasion — i. e., from the beginning of the 
catarrh until the eruption — in 270 cases which we have analyzed was 
as follows : 



1 day or less 35 cases. 

2 days 47 " 

3 " 64 " 

4 " 64 " 

5 " 29 " 



6 days 20 cases. 

7 " 6 ■ 

8 " 2 " 

9 " 2 " 

10 " 1 case. 



From this table it will be seen that the length of the period of 
invasion varies considerably — more, we think, in infants and very young 
children (most of these were under three years old) than in those who 
are older. In the greater number of cases it lasts from two to four 
days. 

Eruption. — The rash usually appears on the third, fourth, or fifth 
day of the disease — in the largest number upon the fourth day. As a 
rule, it is first seen on the back or behind the ears, on the neck, or at the 
roots of the hair over the forehead. It appears as small, dark-red spots, 
which are at first few, scattered, and not elevated, resembling flea-bites. 
In twenty-four hours the macules are much more numerous, and many of 
them have become papules. They frequently group themselves in cres- 
centic forms. They are usually separated by areas of normal skin, but 
where the rash is intense they are frequently coalescent. From the time 
of its first appearance to the full development of the rash on the face. 
is usually about thirty-six hours, but may be from one to three day-. 
With a full eruption there is seen considerable swelling of the face, 
especially about the eyes, and the features are sometimes scarcely 
recognizable. On the second day of the rash it begins to appear upon 
the neck beneath the chin, the upper part of the chest and back; on the 
third day the trunk is covered, and scattered spots are seen upon the 
extremities. The rash appears last upon the lower extremities, and by 
the time it is fully out upon them it lias usually begun to fade from 
the face. In mild cases it remains discrete, but in severe ones it is 



980 THE SPECIFIC INFECTIOUS DISEASES 

frequently confluent upon the face and upon the extensor surfaces of 
the extremities. As a rule, it covers the entire body, even the palms 
and soles. 

The eruption fades slowly in the order of its appearance, and there 
is left behind, in typical cases, a slight brownish staining of the skin 
which often remains for a week or more. The duration of the rash is 
from one to six days, the average being four days. 

There are many cases in which the rash does not follow the typical 
course described: (1) Instead of spreading gradually, the entire body 
may be covered in a few hours. (2) The rash may be hemorrhagic. 
This condition was present in about five per cent of our cases. The 
whole eruption may be hemorrhagic, or it may be so only upon certain 
parts — usually the abdomen or extremities. In such circumstances 
small petechial spots take the place of the macules — the "black measles" 
of the older writers. It is in most cases a bad, but by no means a 
fatal symptom. We have seen it in several cases that were not especially 
severe. (3) The rash may be very faint, and of short duration, being 
scarcely elevated at all. (4) It may consist of very minute papules, 
closely resembling the rash of scarlet fever. It is to be remembered, 
however, that the irregular eruptions of scarlet fever much more fre- 
quently resemble measles than vice versa. (5) It may be very scanty, 
and late in its appearance; particularly in cases of great severity and 
hyperpyrexia — the so-called malignant cases. (6) Temporary recession 
of the eruption may occur at any time during the height of the disease, 
and is usually due to heart failure. A recurrence of the eruption after 
it has run its usual course is something which we have never seen; 
although such cases have been reported, they must be regarded as very 
exceptional. 

During the first two days of the eruption, the local and constitutional 
symptoms increase in severity, both usually reaching their maximum at 
the time of the full development of the rash upon the face. The skin 
is swollen, and the seat of intense itching and burning. The eyes are 
very red and sensitive to light, and there is swelling of the conjunctivae 
with an abundant production of mucus or muco-pus, causing the lids to 
adhere. There is pain on swallowing, also swelling of the glands at the 
angle of the jaw or in the post cervical region. The cough is frequent 
and very annoying. There is complete anorexia, and often diarrhea. 
The tongue is coated, and may show at its margin enlarged papillae, 
somewhat resembling the "strawberry" appearance of scarlet fever. 
As the rash fades the temperature declines rapidly, often reaching the 
normal in two or three days. The catarrhal symptoms now subside, and 
soon the patient is convalescent. Within a day or two after the fever 
has ceased, the rash disappears. 



MEASLES 



081 



DAY 


1 


2 


3 


i 





c 


1 


8 


H 

X 
Z 
Ul 

K 
I 

2 


106° 
105° 
104° 
103° 
102° 
101° 

ioo c 

99° 
98° 


M E 


M E 


M E 


M E 


U E 


M E 


M E 


M E 








X 
















A 














r 


A 














/ 










A 


,/ 


J 




\ 








/ 


V 






s 








/ 










U N 



















Fig. 158. — Temperature Curve in 
Uncomplicated Measles, Show- 
ing the Gradual Rise and Criti- 
cal Fall. Patient ten years old; 



X = first eruption; 
tion on the face. 



= full erup- 



Desquamation. — This begins almost as soon as the rash has subsided, 
and is first noticed on the face and neck, where the eruption first ap- 
peared. The nature of the desquamation is invariably fine, branny 
scales, never in large patches, as in scarlet fever. It is often quite 
indistinct and may be overlooked. Its usual duration is from five to 
ten days. It may, however, be pro- 
longed for two weeks. The amount of 
desquamation varies considerably in 
the different cases. It is most marked 
in those in which there has been an in- 
tense eruption. There is frequently 
] lot iced at this time an odor about the 
patient which is quite characteristic of 
measles. During this stage the cough 
often persists and the eyes remain weak 
and very sensitive to light, but in other 
respects the patient usually feels per- 
fectly well. 

1. The Mild Cases. — The mildest 
cases are distinguished by low tempera- 
ture, which at the height of the erup- 
tion usually reaches 102° or 103° F., but rarely lasts more than four 
days. The eruption is often scanty, and is never confluent. The swell- 
ing, itching, and other cutaneous symptoms are wanting, as is also the 
intense red color of the skin. The rash is frequently obscure, and, with- 
out the other symptoms, hardly suf- 
ficient for diagnosis. The catarrhal 
symptoms are more uniform than 
the rash, but these are very mild as 
compared with the usual form. The 
duration of the rash is shorter, des- 
quamation is scarcely perceptible, 
and there are no complications. 

2. The Cases of Moderate Sever- 
ity. — The course of measles is much 
more regular in children over three 
years old than in infancy. In the 
former, the symptoms of invasion 
come on gradually, and the tempera- 
ture rises steadily until the appearance of the eruption, which is in most 
cases on the third or fourth day of the disease. Pigs. 158 and 159 
represent the typical temperature curve in average uncomplicated cases. 
Such a curve was seen in 44 per cent of 173 cases in which careful 



DAY 


1 


2 


3 


i 


5 


6 


7 


8 


9 


1- 
Ui 

I 

z 

Ul 

a 

X 

< 


ioc c 

105° 
104° 
103° 
102° 
101° 

ioo r 

99° 

98° 


m e 


M E 


M E 


M E 


V. E 


M E 


M f 


M f 


M £ 






X 


X 


x 
















A 
















\ 


\A 


A 
















H 


\ft 












A 






V 


\* 










/ 


J 






V\ 


K/\ 






S 




V 










\A 


















V 


l* 



Fig. 159. — Typical Curve in Uncom- 
plicated Measles, with Gradual 
Rise and Gradual Fall. Patient 
three years old. 



1)82 



THE SPECIFIC INFECTIOUS DISEASES 



observations were made. Sometimes the decline in the fever is very 
rapid, almost a crisis, as in Fig. 158, but more often it falls gradually, 
as in Fig. 159. In such cases the duration of the fever is from five to 
nine days, the average being about a week. The other symptoms follow 
very closely the course of the fever. The maximum temperature is 
nearly always coincident with the full rash upon the face, at this time 

usually being in uncompli- 
cated cases from 103° to 
104° F. in older children, 
and 104° to 105° F. in in- 
fants and young children. 

A not very uncommon 
temperature curve is that of 
Fig. 160, where the onset of 
the disease is marked by a 
sudden rise to 102° or even 
104° F., with a fall nearly 
or quite to normal on the 
second day, after which the 
fever rises gradually, as in 
the first group. This curve was seen in five per cent of our cases. 

3. The Severe Cases. — In Fig. 161 is shown a type of the disease 
which is more frequent in infants than in older children, the important 
features being the late eruption and the continuance of the high fever 
for several days after the rash has begun to fade. Such a prolonged 



DAY 


1 


2 


3 


4 


5 


c 


7 


8 


9 


10 


11 


12 


ui 

X 

z 
<r 

I 
< 


106° 
105° 
104° 
103° 
102° 
101° 

100° 
99° 
98° 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 




M E 


M E 














x 






















X 


X 


X 


















/ 


v 


A 












^ 






A 


/ 


V 


\ 
















/ 


/ 






\ 












\ 




/ 


V 






\ 












V 


V 


,/ 










\A 


v 


r 






V 


V 














\ 


/ 





Fig. 160. — A Not Infrequent Temperature 
Curve in Measles, Showing Abrupt Inva- 
sion, but Subsequent Course Typical. Un- 
complicated case; patient nine months old. 



DAY 


1 


2 


3 


4 


5 


c 


7 ! 


i 9 


10 


11 


12 


13 


14 


15 


16 


17 


1- 

ui 

I 

z 
<r 

I 


106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 


M E 


M E 


M E 


M E 


M E 


M E 
X 


MEM 


E M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 










" 




1 




























A 


A 


/ 


A A 






















A 


J 


\r 


\r 


,/ 


A/ 


iA 


,A 
















A 


h 


/ 


V 


V 


| 


IV 


V 


i/ 














\ 


A 




i/ 






J 








y 












\\ 


y 






1 








\ 


A 


i / 


\ 


























V 


' 


V 


\ 


u 


, r 
































\r 



Fig. 161. — Measles with Prolonged Invasion. Continuance of high temperature 
after full eruption due to severe bronchitis and diarrhea; child two years old. 



course and so high a temperature are almost invariably due to some 
complication, usually bronchopneumonia. When the pneumonia goes 
on to the production of areas of consolidation, the fever usually con- 
tinues tor I luce and sometimes for four weeks, even though terminating 
in recovery. 



MEASLES 



983 



DAY 


1 


2 


3 


i 


5 


6 


7 


8 


9 


10 


1- 
UJ 

I 

Z 
Ul 

<r 

I 
< 

U. 


106° 
105' 
101° 
103' 
102° 

ioi c 

100° 
99 c 

98° 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 






X 














/ 






A 












J 


' 


A 


/ 


ir \ 


j 


vf 


V 


AT 


v 


1 




/ 


\l 






V 


V 


V 


V 






/ 








V 


















y 










1 










I 



































Fig.. 162. — Fatal Attack of Measles, 
Complicated by Bronchopneumonia. 
Very severe symptoms from the onset; 
patient eighteen months old; death on 
tenth day. 



Figs. 162 and 163 illustrate two types of the disease which are often 

seen when measles is complicated by pneumonia. In cases like that 

shown in Fig. 162 the onset is 

abrupt with high temperature, 

prostration, and pulmonary 

symptoms not unlike those of 

primary pneumonia. A tempera- 
ture curve resembling this was 

seen in 28 of 173 cases. The rash 

is often late in appearance; it is 

faint and altogether irregular; it 

may recede after the first day and 

reappear after an interval of one 

or two days. The catarrhal 

symptoms are not marked, but 

the whole force of the disease 

seems to be expended upon the 

lungs. The diagnosis of these cases presents great difficulties, and very 

often it would not be made but for the fact that there are other cases of 

measles in the family or the institution. This form is usually seen in 
infants, and it is usually fatal. 

In other cases marked by a sudden severe 
onset, the system seems to be overpowered by 
the poison of the disease itself. There is pro- 
found depression, and hyperpyrexia, and the 
patient may die from toxemia with cerebral 
symptoms before the appearance of the rash or 
just as it is beginning to show itself. Some- 
times the pulmonary symptoms are entirely 
wanting; at others the rash, if it appears, is 
hemorrhagic. 

In still another group of cases the onset is 
not violent, and for the first two days the attack 
may appear to be of only average severity; but 
there may then develop, often quite suddenly , 
pulmonary symptoms of such intensity as to 
cause death within twenty-four hours. The 
eruption, if seen at all, is faint and not char- 
acteristic (Fig. 163). 

A secondary rise in the temperature after it 
fallen to normal was seen in 8 of 173 cases, being due to the 



DAY 


1 


•z 


■> 


1 


5 


I 
Z 
III 

I 

2 


108 

107 

100 ' 

105° 

101° 

103' 

102' 

101° 

100° 

99 
98 


M E 


M E 


M E 


M E 


M E 








il 


X 








A 


; 










i 






/ 




i 






/ 


! 






A 


/ 








y 








/■ 


j 








/ 





















Fig. 163. — Fatal Attack 
of Measles Complica- 
te BY Bronchopneu- 
monia. Early invasion 
mild, but rapid develop- 
ment of severe symptoms 
on fourth day; rash on 
last day; patient eight 
months old. 



has once 

development of otitis, ileocolitis, or pneumonia 



Complications and Sequelae. — The most frequent and most important 



984 THE SPECIFIC INFECTIOUS DISEASES 

complication of measles is bronchopneumonia, and next to this are ileo- 
colitis, otitis, and membranous laryngitis. Most of the others are in- 
frequent; all complications are relatively infrequent in children over four 
years old. 

J, ungs. — The greatest danger in measles arises from pulmonary 
complications, and the frequency is greatest in children under two 
years of age. In two institution epidemics, embracing about 300 cases, 
nearly all in children under three years old, bronchopneumonia occurred 
in about 40 per cent of the cases. Of those who had pneumonia, 70 
per cent died. Fortunately, such a record as this is never seen outside 
of institutions for young children. Of 2,477 cases, embracing several 
epidemics of measles among children of all ages, pneumonia occurred 
in 10 per cent. Our own experience in the post-mortem room fully 
bears out the statement of Henoch, that a certain amount of pneumonia 
is found in almost every fatal case. Pneumonia is more frequent and 
its mortality is higher in spring and winter epidemics than in those 
occurring at other seasons. It may develop at any time from the begin- 
ning of invasion until convalescence, but it most frequently begins about 
the time of full eruption. 

Lobar pneumonia, although rare, occasionally occurs as a complica- 
tion in children over three years old. In some epidemics many of the 
cases of pneumonia are complicated by severe pleurisy, which adds much 
to the danger from the disease. This form is frequently followed by 
empyema. Pneumonia is always to be suspected when the temperature 
continues high after the full appearance of the rash. 

Bronchitis of the large tubes, always accompanied by tracheitis, is 
seen in every case of measles, possibly excepting a few of the very 
mildest. This is so constant a feature as hardly to be ranked as a 
complication. In nearly all of the severe cases the bronchitis extends 
to the medium-sized and smaller tubes. 

Larynx. — A mild catarrhal laryngitis accompanies almost every case 
of measles. Severe catarrhal laryngitis is present in about ten per cent 
of the cases; it may give symptoms which closely resemble those of 
membranous laryngitis, and the two are no doubt often confused. 

Membranous laryngitis is especially seen in the epidemics of insti- 
tutions. As a cause of death in older children it ranks next to pneu- 
monia. When it develops at the height of the disease, it is sometimes 
due to the streptococcus; but when it develops at a later period, it is 
usually due to the diphtheria bacillus. The streptococcus inflamma- 
tion is in most cases associated with similar changes in the pharynx or 
tonsils, hut not always. True diphtheria, occurring as a complication 
of measles, not infrequently begins in the larynx. The streptococcus 
inflammation may he as serious in this connection as is true diphtheria. 



MEASLES 985 

from the probability, which amounts almost to a certainty, of the de- 
velopment of bronchopneumonia. Xo complication is more to be 
dreaded than this. The diagnosis between the two forms may some- 
times be made by the time of development, but only with certainty by 
cultures. We once saw in measles, where no false membrane was present 
in the rest of the larynx, a necrotic inflammation with almost entire 
destruction of the vocal cords — a condition which may be compared to 
that seen in the tonsils or epiglottis in scarlatina. 

Throat. — A catarrhal angina is part of the disease, and is as charac- 
teristic of measles as is the eruption upon the skin. There is acute con- 
gestion and swelling of the tonsils, uvula, palate, and pharynx. In a 
certain proportion of cases, very much less frequently than in scarlatina, 
the development of membranous patches is seen upon the tonsils and 
adjacent mucous membranes. These occur in two or three per cent of 
the cases. They are to be regarded in the same light as similar condi- 
tions complicating scarlet fever, with this difference, that in measles 
1here is much greater likelihood of the extension of the disease to the 
larynx, while extension to the nose and ears is much less probable. 
True diphtheria, however, may complicate measles, and cases of mem- 
branous inflammation of the tonsils or pharynx developing late in 
measles are usually due to the Klebs-Loemer bacillus. 

Although in most cases the inflammations of the pharynx and ton- 
sils which accompany measles are not serious when they are due to the 
streptococcus, they are sometimes quite as severe as any that accompany 
scarlet fever. They may cause death from general sepsis apart from 
any affection of the larynx. 

Digestive System. — Gastric disorders are not more common than in 
other febrile diseases; but diarrhea is very frequent, and in summer it 
may be even more serious than the pulmonary complications. All forms 
of diarrhea are seen, from that which results from simple indigestion 
to the severe types of ileocolitis. This complication is most often seen 
in children under two years old. The most severe intestinal symptoms 
are not usually seen at the height of the primary fever; but, beginning 
at this time, they often increase in severity, and are most marked 
in the second and third weeks of the disease. 

Catarrhal stomatitis is present in almost every case of measles; less 
frequently the herpetic form is seen. Ulcerative stomatitis is not un- 
common, particularly in institutions. One of the worst complications 
of measles, but fortunately a rare one, is gangrenous stomatitis, or 
noma. This usually occurs in inmates of institutions, or in children 
with bad surroundings who were previously in wretched condition. It 
is nearly always fatal. 

Gangrenous inflammations of other parts of the body arc some- 



!)86 THE SPECIFIC INFECTIOUS DISEASES 

limes seen after measles, especially of the ear, the vulva, or the prepuce. 

Nervous System. — Convulsions are seldom seen at the onset of 
measles. During the progress of the disease they are not so rare, and 
may occur in connection with otitis, meningitis, or severe broncho- 
pneumonia — chiefly in infants. 

Meningitis is rare, but either the simple or the tuberculous form 
may occur, more often, however, as a sequel than as a complication. 
Mental disturbance, usually of a temporary character, occasionally fol- 
lows measles. In the epidemic of 108 cases reported by Smith and Dab- 
n ey, insanity was noted three times, all the cases terminating in recovery. 
Epilepsy and chorea are rare sequelae. 

Ears. — Otitis is a frequent complication in some epidemics; in 
others it is seldom seen. In one hospital epidemic it was noted in II 
per cent of the cases. This epidemic occurred in early spring and 
affected very young children, both of which circumstances are favor- 
able for the development of otitis. Usually both ears are affected, but 
the otitis of measles is, as a rule, less serious than that of scarlet fever. 

Eyes. — Simple catarrhal conjunctivitis accompanies nearly every 
case of measles. In the severe form there is a mucopurulent catarrh, 
which may attain any degree of severity. In neglected cases, and among 
children who are poorly nourished, especially in asylums, the disease is 
apt to extend to the cornea. Chronic conjunctivitis often persists after 
measles, particularly in the class of children just mentioned. 

Lymph Nodes. — Swelling of the lymphatic glands of the neck is 
frequent, but not generally severe, and rarely terminates in suppuration. 
Chronic enlargement may continue for months, and sometimes the 
glands may become tuberculous. Similar changes and similar conse- 
quences may occur in the glands of the tracheobronchial group. 

Kidneys. — The infrequency of renal complications in measles is in 
striking contrast to scarlet fever. Transient febrile albuminuria is not 
uncommon, but a serious degree of nephritis, either clinically or at 
autopsy, we have never seen, and literature furnishes but few cases. 

Heart. — Both endocarditis and pericarditis have occurred in the 
course of measles, but they belong to the rare complications. The same 
may be said of changes in the muscular walls of the heart. 

Shin. — As complications, erysipelas, furunculosis, impetigo, and 
pemphigus have been noted; but all are rare. 

Hemorrhages. — Associated with the hemorrhagic type of the erup- 
tion, severe and even fatal hemorrhages may occur from the mucous 
membranes, and the latter are sometimes seen without the hemorrhagic 
eruption. 

Blood. — In cases which have been studied early in the stage of incuba- 
tion ;i lymphocytic leucocytosis has been observed. This is succeeded by a 



MEASLES 987 

leucopenia in which there is a reduction in the lymphocytes both actual 
and relative. This condition is marked one or two days before the erup- 
tion — sometimes even earlier — and continues during the height of the 
disease. A decided leucocytosis during this time or later points to a 
complication. 

Other I /if pet Ions Diseases. — Measles in institutions is often compli- 
cated by diphtheria. Scarlet fever or varicella occasionally occurs dur- 
ing measles, though it is rare that the two eruptions are exactly simul- 
taneous. Epidemics of measles and whooping-cough frequently occur 
together or follow each other. The relation of measles to tuberculosis 
seems to be particularly close. In some cases general or pulmonary 
tuberculosis follows directly in the wake of measles, which seems to 
furnish, especially in the lungs, conditions which are favorable for the 
development of latent tuberculosis. As a late manifestation the most 
common one is tuberculosis of the bones, occurring as hip-joint disease, 
caries of the spine, etc. An attack of measles in a child with latent tuber- 
culous antecedents should, therefore, always be looked upon with appre- 
hension. 

Diagnosis. — A sign of the greatest diagnostic value is the buccal 
eruption. Although it appears that this was described many years ago 
by Flindt, of Denmark, it is to Koplik that the credit belongs for its 
independent discovery and for the appreciation of its diagnostic signifi- 
cance. The unit of the eruption is a bluish-white speck upon a red 
ground; only a few of these are present for the first twenty-four or 
thirty-six hours; after this the mucous membrane may be fairly pep- 
pered with them. Often they are not seen except by careful search, for 
which strong sunlight is necessary; artificial light is not satisfactory. 
The spots are best seen on the inside of the cheeks opposite the molar 
teeth, and in most cases only there; but they may be present on almost 
any part of the buccal mucous membrane. Their diagnostic value is 
due to the fact that they are nearly always present, that they are not 
found in other diseases, and that they usually appear two or three days 
before the skin eruption. This generally disappears at the time of full 
eruption. 

We have records of an epidemic of 187 cases in an institution in 
wlii(l) careful notes were made regarding this buccal eruption: it was 
unmistakably present in 169 cases, absent in 8, doubtful in 10. In 78 
cases, fever, rash, and Koplik's sign were all present at the first obser- 
\ at ion. Tn 54 patients the sign was noted one day before the rash; in 
25, two days before; in 4, three days before; in ?>, four days before; 
and in 2, five days before. Tn 2 tile spots were not seen until after the 
skin eruption; in one case they were present without any eruption. As 
this patient had been exposed and had a prolonged fever, it seems fair 



988 THE SPECIFIC INFECTIOUS DISEASES 

to regard the case as one of measles. In only one case was the buccal 
eruption seen before any elevation of temperature. 

These facts, amply confirmed by other observations, indicate that 
Koplik's sign is of value in enabling us to make a diagnosis from one 
to three days before it is possible by the skin eruption, also in furnish- 
ing a means of distinguishing measles from the other eruptive fevers, 
as well as from rashes due to drugs, antitoxin, etc. 

Other important symptoms are the coryza, the gradual rise in tem- 
perature, and the eruption which appears first upon the neck and face, 
and slowly extends over the body. Cases which present the greatest diffi- 
culties in diagnosis are usually the very severe ones and those in infants. 

Prognosis. — This depends upon the age and previous condition of 
the patient, the character of the epidemic, and the season of the year. 
Except in children under three years of age, the deaths from measles 
are few; but in institutions containing young children, no epidemic 
disease is so fatal. 

The general mortality of the disease is from 4 to 6 per cent; but in 
epidemics in institutions for young children it lias, in onr experience, 
ranged from 15 to 35 per cent. The following table gives the 'figures of 
an epidemic in one institution : 

From six to twelve months 42 cases; mortality, 33 per cent. 

" one to two years 51 " " 50 " " 

" two to three years 27 " " 30 " " 

" three to four years 20 " " 14 " " 

" four to five years 3 " " " " 

In any single case the important symptoms for prognosis are the 
temperature and the character of the eruption. An initial temperature 
above 103° F., or one which remains high until the eruption appears, is 
a bad symptom. So also is one which rises after a full eruption, or 
which does not fall as the rash fades. The following table shows the 
highest temperature and mortality in 161 hospital cases: 



Highest temperature not over 102° F. 6 cases; mortality, per cent. 

102° to 103.5° F. 14 " " 7 " " 

« « 104 ° « 104 5 o F 49 u a 16 u u 

105° " 105.5° F. 65 " " 40 " " 

106° F. or over.. 27 " " 80 " " 

A favorable eruption is one of a bright color, covering the body, 
remaining discrete, and spreading gradually. It is unfavorable for the 
eruption to appear late, to be very faint, scanty, or hemorrhagic, or to 
recede suddenly, as this is usually due to a weak heart. 

Of 51 fatal cases, the cause of death was bronchopneumonia in 45, 
ileocolitis in L and membranous laryngitis in 2. More than half the 



MEASLES 089 

deaths occurred during the second week, the earliest being upon the 
fifth day of the disease. 

The ultimate result of an attack of measles may not be evident for 
some time. Cases in which the temperature persists for two or three 
weeks without assignable cause after the disease is apparently over, 
should be watched with the greatest solicitude. The explanation of this 
is most frequently to be found in the lungs, although the physical signs 
are often obscure. The condition may be either pneumonia or pulmonary 
tuberculosis. Even though the attack of measles may not have been in 
itself severe, seeds are often sown the full fruits of which are not seen 
until long afterward. Chronic glandular enlargements which may or 
may not be tuberculous, chronic bronchitis, chronic laryngitis, subacute 
or chronic nasal catarrh, hypertrophy of the tonsils, and adenoid growths 
of the pharynx — all are frequent sequelae. 

Prophylaxis. — Measles is often regarded by the laity as so mild a 
disease that its prevention is thought to be of little importance, and no 
effort is made to limit its extension. The great probability that every 
person at some time in his life will have the disease, is no justification 
of unnecessary exposure. Although in older children measles is usually 
mild, this is not so in infants, who should be carefully protected from 
exposure. Special care should also be taken to avoid the exposure of 
delicate children or those with a strong tendency to pulmonary disease 
or to tuberculosis. In institutions it is of the utmost importance to 
secure prompt and complete isolation of the first case which appears. 

The disease being nearly always spread by the patient, it follows 
that while early isolation is more important, there is not required the 
same thorough disinfection of apartments which should follow every 
case of scarlet fever. In an institution, the ward or cottage from which 
a case has been removed should be quarantined for at least sixteen days 
after the appearance of the last case, and absolute security can not be 
said to exist until the end of three weeks. The same rule should be 
applied in private families where children who have been exposed should 
be quarantined apart from the patient, but not sent away. In ordi- 
nary circumstances the quarantine of a case of measles should be placed 
at two and a half weeks, or ten days from the beginning of the eruption. 
It should be continued longer if there is otitis, or a nasal discharge. 

Thorough cleansing and disinfection of the sick-room should be done 
before it is again occupied by children, and it should remain vacant 
at least two weeks. Children should be kept from all schools while 1 
the disease is in their homes, chiefly because they are otherwise liable 
to spread the disease while suffering from the early symptoms of 
invasion. 

Treatment. — Measles is a self-limited disease, and there are no known 
33 



990 THE SPECIFIC INFECTIOUS DISEASES 

measures by which it can be aborted, its course shortened, or its severity 
lessened. The indications are therefore to treat serious symptoms as 
they arise, and, as far as possible, to prevent, complications, which are 
the principal cause of death. 

While the bed should be screened to protect the sensitive eyes of the 
patient it is not desirable to exclude sunlight from the sick-room. Every 
child with measles should be put to bed and kept there with light cover- 
ing during the entire febrile period. There can be no possible advantage 
in causing a child to swelter by thick covering, under the delusion that 
the disease may be modified thereby. The food should be light, fluid, 
and given at regular intervals. If the conjunctivitis is severe, iced 
cloths should be applied to the eyes, which should be kept clean by 
the frequent use of a solution of boric acid, the lids being prevented 
from adhering by the application of vaseline or some simple ointment. 
The intense itching and burning of the skin may be relieved by inunc- 
tions of plain or carbolized vaseline, or by bathing with a solution of 
bicarbonate of soda. The cough, when distressing, may be allayed by 
small doses of opium, either in the form of codein or the brown mix- 
ture. The restlessness, headache, and the general discomfort which 
accompany the height of the fever may be relieved by an occasional dose 
of phenacetin. As soon as the rash has subsided, a daily warm bath 
should be given, followed by inunctions to facilitate desquamation. 

The important indications to be met in the severe cases are very 
high temperature, cardiac depression, and nervous symptoms — dulness, 
stupor, sometimes coma, or convulsions. In some of the cases there is 
in addition dyspnea and cyanosis, showing severe acute pulmonary con- 
gestion. For the nervous symptoms and high temperature, nothing is so 
reliable as the cold bath or pack and the nearly continuous use of ice 
to the head. We do not think there is any evidence that the use of cold 
increases the liability to pneumonia; but cold extremities, feeble pulse, 
and cyanosis, when associated with high temperature, call for the hot 
mustard bath, although ice should still be applied to the head. The indi- 
cations for stimulants and the methods of using them are the same as in 
bronchopneumonia, which is usually present in cases requiring them. 

To diminish the chances of pneumonia, it is necessary that every 
patient should be kept in bed during the attack, and care exercised to 
moid exposure. But still more important is it in hospitals and institu- 
t ions where most of the cases of pneumonia occur, to allow the patients 
plenty of air space, never crowding them together in small wards. If 
possible, cases complicated by pneumonia should be separated from sim- 
ple cases. The pneumococcus and the streptococcus are found in the 
month in such numbers that systematic disinfection of the mouth may 
prove of some value. 



RUBELLA 991 

The danger of diphtheria as a complication may be greatly lessened 
if during epidemics of measles in institutions every ease receives an 
immunizing dose of diphtheria antitoxin. 

The bronchitis and bronchopneumonia of measles should be man- 
aged as when they occur as primary diseases, since the coexistence of 
measles furnishes no new indications. The same is true of the diarrhea, 
conjunctivitis, otitis, membranous laryngitis, pharyngitis, and tonsillitis. 
•Should cultures show the presence of the diphtheria bacillus, the case 
should be treated like one of diphtheria. 

During convalescence the eyes should be used very carefully for at 
least several weeks. Should the cough and slight fever persist, with or 
without physical signs in the chest, the patient should, if possible, be 
sent away to a warm, dry, elevated district, as the development of 
tuberculosis is always to be feared. Cod-liver oil should be given con- 
tinuously throughout the succeeding cool season, and iron and other 
tonics according to indications. The cough itself should be treated as 
when it follows an ordinary bronchitis, creosote being more generally 
useful than any other drug. 



CHAPTER III 
RUBELLA 

(German Measles; Rotheln) 

Rubella is a contagious eruptive fever which is rarely seen except 
when prevailing epidemically. It is characterized by a short invasion, 
with mild, indefinite symptoms, usually lasting but a few hours, and by 
an eruption which is generally well marked but of variable appearain :e. 
The constitutional symptoms are very mild, and the disease rarely proves 
fatal, not often being even serious. For a long time rubella was con- 
founded with measles and scarlet fever, as the eruption sometimes resem- 
bles one and sometimes the other disease. Its identity is now fully estab- 
lished, and, as Strumpell well says, its existence is doubted only by those 
who have never seen it. 

Rubella is not a simple affection of the skin; if prevails independently 
either of measles or of scarlei fever; it- incubation, eruption, invasion, 
and symptoms differ materially from those <>f both these diseases; it 
attacks indiscriminately and with equal severity those who have had 
measles and scarlet fever and those who have not, nor does it protecl 
in any degree against either of them; it never produces anything but 



992 THE SPECIFIC INFECTIOUS DISEASES 

rubella in those exposed to its contagion; it occurs but once in the same 
individual. 

Etiology. — Eubella is beyond question contagious, but is decidedly 
less so than either measles or scarlet fever; so that some observers 
have doubted its contagion altogether. It can be communicated at any 
time during its course, but is especially contagious during the early 
stage. Epidemics usually prevail in the winter or spring. As in the 
other eruptive fevers, a striking immunity is seen in infants under six 
months old; but, with this exception, all ages are liable to the disease. 

The incubation of rubella varies considerably; the usual period is 
from fourteen to twenty-one days, although the limits are from ten to 
twenty-two days. 

Symptoms. — Invasion. — This is rarely more than half a day, and in 
many cases no prodromata whatever are noticed, the rash being the first 
thing to attract attention. In a few cases there are mild catarrhal symp- 
toms, with general malaise and slight fever. At other times there may 
be vomiting, convulsions, delirium, epistaxis, rigors, headache, or dizzi- 
ness; but all are to be regarded as very exceptional. 

Eruption. — Frequently a child wakes in the morning covered with 
the rash, no symptoms having been previously noticed. It generally ap- 
pears first upon the face, and spreads rapidly to the whole body, the lower 
extremities being last covered. Less than a day is usually required for 
its full development. Exceptionally the eruption comes first upon the 
chest and back, and sometimes nearly the whole body is covered almost 
at once. The rash is occasionally observed in the roof of the mouth 
before it is visible on the face. In a considerable number of cases the 
entire body is not covered ; but the rash is more constantly seen upon the 
face than upon any other part of the body. 

Its character is subject to considerable variation. The eruption is 
most frequently composed of very small maculopapules ; they are of a 
pale-red color, and vary in size from a pin's head to a pea. The spots 
are usually discrete, but may cover the greater part of the body. On the 
face it is frequently confluent, and often appears here as large, irregular 
blotches of a red color. From this description the rash will be seen to 
resemble that of measles more than that of any other disease. Very 
often, however, there is a fairly uniform red blush which bears a close 
resemblance to the rash of scarlet fever; but even in such cases there 
will nearly always be found upon some part of the body, usually the 
wrists, fingers, or forehead, some typical maculopapules. Between these 
two extremes all variations are seen. The color of the eruption is some- 
times dark red, and rarely it has been noted to be hemorrhagic. The 
degree of elevation above the surface is also variable; sometimes this is 
so marked as to give to the skin a "shotty" feel, while in others the 



RUBELLA 993 

elevation is scarcely perceptible. The duration of the eruption is usually 
three days. Occasionally it lasts only two days, and it may last but one ; 
it is rare for it to remain as long as four days. It fades in the order 
of its appearance, and more rapidly than the eruption of measles. A 
slight brown pigmentation of the skin sometimes remains for a few days 
after the rash. 

The highest temperature is coincident with the full eruption; this 
does not usually exceed 101°, and often it is only 100° F. As a rule, 
the temperature continues but two days, falling as the eruption fades. 
Very often the fall to normal is abrupt. Earely more severe cases are 
seen in which the fever lasts for two or three days, being 101° or 102° F. 
during the invasion, and rising to 103° F. or more during the full erup- 
tion. The other symptoms are in most cases even less marked than the 
fever. Occasionally catarrhal symptoms resembling a mild attack of 
measles are present, or a sore throat suggesting mild scarlet fever; but 
more frequently all these symptoms are absent. The eruption is usually 
out of all proportion to the other signs of disease. 

Swelling of the post-cervical glands is one of the most constant fea- 
tures of rubella. In most epidemics it is seen in nearly all cases; but 
as a symptom for differential diagnosis it is not of great importance, as 
it is not uncommon in measles and scarlet fever. The glandular swelling- 
is most marked at the height of the disease; it is never very great, and 
subsides slowly without suppuration. Vomiting and diarrhea are rare. 
Swelling and itching of the skin are usually present and sometimes 
marked. There is no leucocytosis in this disease. 

Forchheimer has described an eruption on the mucous membrane of 
the throat, or "enanthem," which he believes to be characteristic. It 
consists of minute, bright, rosy-red points, seen on the uvula and soft 
palate, rarely on the hard palate. It is present only during the first 
twenty-four hours. 

Desquamation. — This is exceedingly variable. It is sometimes en- 
tirely wanting; writers who have observed some fairly typical epidemics 
have stated that it did not occur. In most cases, however, some des- 
quamation is present, though it may be so slight as to be discovered only 
by a close examination. It is usually in the form of fine scales over the 
body and extremities. In a few cases it is more pronounced, and may 
be in larger flakes or patches. 

Prognosis. — There are few diseases so free from danger as rubella. 
Complications and sequelae are very seldom seen, and when present are 
usually of the mildest character. 

Diagnosis, — The principal interest attaching to rubella is in its diag- 
nosis. This is a matter of extreme difficulty, and often it is an impossi- 
bility. The characteristic thing about the disease is a well-marked erup- 



994 THE SPECIFIC INFECTIOUS DISEASES 

tioii with very few other symptoms. Cases so closely resemble mild 
scarlet fever that the differentiation by symptoms may be impossible; it 
must be made by the circumstances in which the disease occurs, espe- 
cially a prevailing epidemic. Scarlet fever with a low temperature and 
abundant rash should always be regarded with suspicion; also an abun- 
dant rash with little or no desquamation. The longer period of incuba- 
tion in rubella is often of much assistance. Koplik's sign furnishes a 
valuable means of distinguishing measles from rubella. The difficulties 
in diagnosis can be appreciated only by one who has seen epidemics of 
measles and scarlet fever in institutions, and has watched the exceed- 
ingly mild course of undoubted cases of these diseases which have there 
occurred. 

It is always hazardous to make the diagnosis of rubella unless the 
disease is prevailing epidemically. Sporadic cases in which this diagnosis 
is made are, we believe, almost invariably instances of mild measles or 
scarlet fever. The first cases of rubella in an epidemic are usually over- 
looked. The continued absence in succeeding cases of the characteristic 
symptoms and complications of measles or scarlet fever should suggest to 
the physician that he is probably dealing with rubella. 

Treatment. — None whatever is required for the disease excepting 
isolation, which should be complete until the diagnosis is positively deter- 
mined; after this it is hardly necessary. The individual symptoms and 
complications are to be treated as they arise. 



CHAPTER IV 
VARICELLA 

(Chicken-pox) 

Varicella is an acute, contagious disease, characterized by a cuta- 
neous eruption of papules and vesicles and by mild constitutional symp- 
toms, serious complications and sequelae being very rare. Although long 
confounded with varioloid, its existence as a distinct disease has been 
generally admitted for many years. 

Etiology. — It is well established that the contagium of the disease is 
contained in the vesicles, as it may be communicated by inoculation with 
their contents. The specific poison, however, has not yet been isolated. 
\ aricella is contracted by exposure to another case or through the me- 
dium of a third person. It affects children of all ages, one attack being 
as a rule protective. It is very contagious, resembling measles in this 



VARICELLA 995 

respect. The period of incubation is quite uniformly from fourteen to 
sixteen days. 

Symptoms. — Slight fever and general indisposition may be noticed 
for twenty-four hours before the appearance of the eruption, but in most 
cases the eruption is the first symptom. It usually appears first upon 
the face or trunk, as small, red, widely scattered papules. The papules in 
most cases come in crops, new ones continuing to appear for three or 
four days, even upon the same part of the body. The earlier ones have 
generally begun to dry up by the time the later ones appear, so that jill 
stages of the eruption may be present at one time in the same region, 
this being one of the diagnostic features. The papules are at first very 
small, but gradually increase in size, and are surrounded by an areola 
from one-fourth to half an inch in width. Many of them go no further 
than this stage, but the majority become vesicular. The vesicles are usu- 
ally flat, and vary a good deal in size — the largest being about one-fourth 
of an inch in diameter. The process of drying up generally begins at the 
center; this causes a slight depression, giving the vesicle a somewhat 
umbilicated appearance. The areola is most distinct at the time of the 
fully formed vesicle, and fades as the latter dries. Crusts now form, 
which fall off in from five to twenty days, depending upon the depth to 
which the skin has been involved. In the majority of cases no mark is 
left, but after the most severe attacks, when the true skin has been in- 
volved, scars remain, and occasionally there is quite deep pitting. Such 
marks are few in number, and are most likely to occur upon the face. 

Sometimes, especially upon hands and feet, the vesicle appears with- 
out having been preceded by a papule ; often there is no areola, and the 
vesicle resembles a drop of water upon healthy skin. In most cases pus- 
tules are not seen, but they may develop in consequence of irritation or 
infection, the result of scratching, or in children who are poorly nour- 
ished. Under these circumstances deeper ulceration may occur, lasting 
for weeks. In rare cases there may be a necrotic inflammation about the 
site of the pock, a condition to which is sometimes given the name vari- 
cella gangrenosa. It is not peculiar to varicella, and is described else- 
where under the head of Gangrenous Dermatitis. 

The pocks are usually most abundant over the back and shoulders. 
In mild cases only twenty or thirty may be found upon the entire body, 
but in severe cases the skin in certain regions may be nearly covered. 
The eruption is never c onfluent. The pocks are usually seen on the 
hairy seal]), and often on the mucous membrane of the mouth or pharynx 
— a point of some diagnostic value. In the latter situation the appear- 
ance is first as a tiny vesicle, and later as a superficial ulcer resembling 
that of herpetic stomatitis. "Marfan and Halle have described cases of 
varicella of the larynx. Croupy symptoms were present, and in one 



996 THE SPECIFIC INFECTIOUS DISEASES 

case which proved fatal from pneumonia a tiny ulcer was found on the 
vocal cords. 

The temperature is highest when the eruption is most rapidly appear- 
ing, this usually being the second or third day. In an average case it 
reaches only 101° or 102° F., and lasts but two days; in severe cases it 
may rise to 104° or 105° F., and lasts for four or five days. It falls 
gradually to normal as the rash fades. The other symptoms are mild 
and not characteristic. 

Complications. — The most important complication is erysipelas, 
which develops about the pocks, particularly when they are deep and at- 
tended with some ulceration. We have known of several fatal cases from 
this cause. Adenitis, either simple or suppurative, and abscesses in the 
cellular tissue, are occasionally seen. Nephritis is very infrequent, but a 
number of cases are recorded. It may occur at the height of the dis- 
ease, but more often at a later period, like the nephritis, of scarlet fever. 
Varicella is quite frequently complicated by other infectious diseases. 
We have seen coincident scarlet fever in a number of cases. Severe nerv- 
ous lesions occasionally follow varicella, the most frequent being enceph- 
alitis. We have seen transverse myelitis develop in a boy of seven after 
an attack of varicella. 

Diagnosis. — The diagnosis of varicella is usually easy, provided the 
following points are kept in mind : first, that the eruption comes out 
slowly and in crops, so that papules, vesicles, and crusts may be seen upon 
the skin in close proximity; secondly, that the umbilication is due only 
to the mode of drying up of the vesicle, which begins at the center; 
thirdly, the appearance of the pocks upon the mucous membranes, and 
the history of exposure. It is distinguished from urticaria and other 
forms of skin disease by the presence of fever and often by the lesions in 
the mouth. Cutaneous inoculations from fresh vesicles, as first practiced 
by Kling, apparently protect against varicella. At the site of inocula- 
i ion small localized lesions are produced, but there are no general symp- 
toms. 

Treatment. — Although it is usually a trivial disease, isolation of cases 
of varicella should be enforced in schools and in institutions containing 
many infants. In the home, unless other children are delicate or in 
poor condition, quarantine is unnecessary. The disease may probably be 
conveyed as long as the crusts are present, hence isolation should be 
maintained until they have fallen off. In most cases constitutional 
symptoms of the disease are so mild as to require no treatment. 

Locally, the itching, when annoying, may be allayed by sponging 
with a solution of bicarbonate of soda, a one-per-cent solution of car- 
bolic acid or the use of carbolized vaseline. When the crusts have formed, 
this ointment or vaseline containing two per cent ichthyol should be 



VACCINATION 097 

applied. Care is necessary to keep the skin clean, and, in the case of 
infants, to prevent scratching. In severe cases the urine should invari- 
ably be examined. 



CHAPTER V 
VACCINIA— VACCINATION 

Vaccinia (cowpox) is a febrile disease induced in man by inocula- 
tion with the virus obtained either directly from the cow (bovine virus) 
or from a person who has been inoculated (humanized virus). The dis- 
ease is not contagious in the ordinary sense of the term, but is communi- 
cated by inoculation either accidental or intentional. 

The protection against smallpox which vaccination affords is one of 
the best attested facts in medicine. Its effect when systematically prac- 
ticed is graphically shown in the accompanying chart (Fig. 164). It is 
the imperative duty of the physician to see to it that every young infant 
is vaccinated. 

Re-vaccination. — Regarding the duration of the protective power of 
a single vaccination, positive statements are impossible. Nearly all 
writers are agreed that vaccination should be done in infancy, again at 
puberty, and a third time at about the age of twenty or twenty-five. 
Many also insist upon re-vaccination at about the seventh year. It is a 
safe rule when smallpox is prevalent to vaccinate every person who has 
not been successfully vaccinated within five years. 

Choice of Lymph. — The substitution of bovine for humanized virus 
is now well-nigh universal. It has precluded the possibility of trans- 
mitting syphilis and greatly lessened the chances of other forms of in- 
fection. A still further advance was made by the introduction of 
"glycerinated" lymph. As now prepared, the lymph is taken from the 
calves under the most rigid aseptic precautions and emulsified with 
glycerin. The few saprophytic bacteria present soon die, so that when 
properly prepared the glycerinated virus is practically sterile. It should 
not be distributed until it has been carefully tested for pathogenic organ- 
isms of all kinds, particularly the tetanus bacillus. It is preserved and 
distributed in capillary tubes hermetically sealed ; these are much safer 
than quills or ivory points, which may easily become contaminated by 
handling. After the lymph has been taken, the calves arc killed in order 
to make certain that they were free from disease. The practical advan- 
tages of glycerinated lymph are so great that it has been officially 
adopted by the Governments of the United States, Great Britain, Ger- 
many, and many other countries. 



098 



THE SPECIFIC INFECTIOUS DISEASES 



Noguchi has succeeded in cultivating vaccine virus in vitro. It can 
readily be produced in indefinite quantities; so that we may soon hope 
to be supplied with virus in pure culture, free from all possibility of 
bacterial contamination from animal sources. Experience with its use 
indicates that it is quite as effective as the ordinary bovine virus. 



PRUSSIA. 



WITH COMPULSORY VACCINATION, AND 

COMPULSORY RE-VACCINATION 

AT THE AGE Of 12. 



After the lav of 1874 

was passed. 



1808-1874 

Average 

yearly Deaths 

from small. 

pox in every 

100,000 
Inhabitants. 



IL^ilV 



Annual Deaths 
from small-pox 
la every 100,000 

inhabitants. 



HOLLAND. 



After the law of 1878 

was passed. 



1860-1872 
Average 
yearly Deaths 
from small- 
pox In every 

100,000 
Inhabitants. 



ll 



I. ..hi 



U, 



Annual Deaths 

from small-pox 

In every 100,000 

Inhabitants. 



AUSTRIA. 



-120 



_m> 



.100 



_ 60 



1808-1874 

Average 

yearly Deaths 

from small. 

pox In every 

100,000 ' 
Inhabitants. 



■c-c-t-r-»50aococo 

Annual Deaths 

from small-pox 

In every 100,000 

Inhabitants. 



80 2 

1 



i 

50G 



_40 



Fig. 164. — Table Showing the Protective Power of Vaccination. (Carsten.) 



Time for Vaccinating. — In selecting a time for vaccination, the 
child's age and general health must be taken into consideration. It is 
pretty well established that the constitutional disturbance is much less 
in infancy than in later childhood; and there is besides in infancy less 
chance of accidental infection of the vaccine wound. Between the ages 



VACCINIA 999 

of two and six months seems the best general time for vaccination. In 
delicate infants or in those whose nutrition is a matter of great difficulty, 
those who are syphilitic, those suffering from eczema or any other form 
of active skin disease, vaccination should be deferred until the child is 
in good condition, unless he is likely to be exposed to smallpox. 

Methods of Vaccinating. — In our experience it is preferable to vac- 
cinate in a single place rather than to make two or three inoculations. 
Either the leg or the arm may be chosen ; in young infants it is usually 
easier to protect the vaccine sore upon the leg than upon the arm; in chil- 
dren old enough to run about, the arm is to be preferred, as being more 
easily kept at rest. The point selected for inoculation should be either the 
outer aspect of the left calf, about the junction of the middle with the 
upper third of the leg, or, if the arm is chosen, the insertion of the left 
deltoid. Vaccination should be regarded as a minor surgical operation 
and the hands of the physician, as well as the arm of the patient, should 
be washed with soap and water, dried, and the skin then washed with 
alcohol. 

The New York Health Department supplies with each tube of lymph . 
a sterilized needle and a rubber bulb. A single scratch not more than 
one-fourth of an inch long is made with the needle just deep enough to 
draw blood; or a minute scarification may be made not over one-eighth 
of an inch in diameter. The ends of the capillary tube are broken off. 
and the lymph blown out of the tube upon the scratched surface and 
rubbed in for a full minute. The wound should not be covered until 
dry; a sterilized bandage should then be applied. The limb should not 
be washed for twenty-four hours. 

The Normal Course of Vaccinia. — The course of a proper vaccina- 
1 ion-pock is quite uniform, and one which does rot follow this course 
should not be considered protective. The wound heals and nothing is 
noticed until the third or fourth day, when a red papule makes its ap- 
pearance. Usually in twenty-four hours more a small vesicle appears 
which enlarges until the sixth or seventh day, reaching its full develop- 
ment about the ninth day. Its shape and size depend somewhat upon 
the extent of the scarification (Figs. 165-169). The vesicle is usually 
from one-fourth to one-half inch in diameter ; it is of a pearly-gray color 
and has a depressed center. During the next two days an areola forms 
about the vesicle extending from it a variable distance, usually for one or 
two inches into the healthy skin, lis size depends upon the intensity of 
the infection. This areola, is normally of a bright-red color and accom- 
panied by some induration. It is generally at its height about the ninth 
day. The vesicle usually dries down to a firm, dark crust which remains 
from one to three weeks and falls off, leaving a bluish scar which fades to 
white, becoming somewhat honey-combed. When the process is at its 





Fig. 165.— Fifth day. 



Fig. 166.— Seventh day. 




Fig. 167. — Ninth day. 




168. — Eleventh day. 




day. 



Figs. 165-169. — Vaccine Vesicles. (Two-thirds natural size.) 
1<1GS. 165, 166, 167, and 168 show typical appearance of vesicle at the different stages 

when a very small scarification is made. 
I' i<;. 169 shows the effect of a larger scarification with a more intense areola. The amount 
of inflammation is excessive but not unusual. 

1000 






VACCINIA 



1001 



height some constitutional disturbance is usually present; there may be 
loss of appetite, fretfulness, and general indisposition, and the tempera- 
ture is usually elevated from one to three degrees. The lymph nodes in 
the groin or axilla may be tender and swollen. These symptoms gener- 
ally last for three or four days. 

If in a young infant the first inoculation is unsuccessful, at least 
three trials should be made with good virus, and in the event of further 
failure, after a year vaccination should be repeated. A failure to inocu- 
late does not mean insusceptibility to smallpox, as is often popularly be- 
lieved, but most frequently arises from the fact that the virus is inert. 
We have known one case in which the seventh, and another in which the 
thirteenth, inoculation was 
successful after previous 
failures; occasionally there 
are seen children who can 
not be inoculated at all. 

Constitutional symp- 
toms, as previously stated, 
may be absent in very young 
infants; but in others there 
is quite constantly present a 
fever which runs a fairly 
regular course. It usually 
begins on the fourth or fifth 
day, is remittent in type, 
and rises gradually, reach- 
ing its highest point with 
the full development of the 

vesicle. At this time even without complications it may touch 104° or 
105° F. The duration of the fever in cases running the usual course is 
four or five days. Accompanying the fever there may be anorexia, rest- 
lessness, loss of sleep, slight indigestion, and other symptoms of a general 
indisposition. 

Both tbe local and the general symptoms are sometimes more severe. 
This may depend upon the susceptibility of the child, even though the 
lymph is pure and the vaccination properly done. The original vesicle 
may be much larger than usual, and small secondary vesicles may form 
in the neighborhood. In very rare instances a generalized eruption of 
true vaccine vesicles occurs with f r ever and other genera] symptoms of cor- 
responding severity (Fig. 170). Single vesicles may be produced on dis- 
tant parts of the body as a result of auto-inoculation, usually by scratch- 
ing. When eczema of the face is present, inoculation Is not infrequently 
carried thither. Most of the very sore anus and legs, however, are due 




Fig. 170. 



Generalized Vaccinia. 
years old. 



Boy eight 



1002 THE SPECIFIC INFECTIOUS DISEASES 

to infection from pyogenic bacteria accidentally introduced at the time 
of vaccination but more often subsequently. In the milder cases the 
swelling and other evidences of local inflammation are more marked than 
in a normal vaccination ; a drop or two of pus forms beneath the crust, 
and when the latter comes away an excavation is left which heals in two 
or three weeks. Or, the inflammation may extend more deeply into the 
connective tissue, to be followed by more extensive suppuration or slough- 
ing, leaving an ugly ulcer an inch or more in diameter which slowly fills 
by granulation in from five to eight weeks. Sometimes the period of 
incubation is unduly prolonged, so that the vesicle does not form until 
the twelfth or fourteenth day, although its subsequent course may be 
quite normal. In other cases the incubation is very much shorter than 
usual, and the vesicle may appear as early as the fourth or even the 
third day. 

Much has been written about the so-called "raspberry excrescence" 
which not very infrequently takes the place of a proper vesicle. It is of 
a dark-red color, elevated, smooth or slightly granular, not sensitive, 
having no areola and no constitutional symptoms. It generally per- 
sists for two or three weeks, and slowly disappears, leaving no scar. It is 
usually the result of virus of feeble activity, and if it gives any protection 
it is very slight. Such cases should always be re-vaccinated, and in our 
experience re-vaccination is usually successful. 

Complications and Sequelae. — Post-vaccine eruptions are many and 
of great variety. The most frequent is a general roseola, usually occur- 
ring at the height of the local process. Other eruptions seen are urti- 
caria, and, rarely, purpura. Complications are chiefly from accidental 
infection. Syphilis and tuberculosis are excluded by the modern method 
of procuring the lymph. Tetanus in rare instances has followed vacci- 
nation. It may result either from introduction of the bacilli with the 
vaccine lymph but more often from subsequent accidental infection of 
the wound or sore. Cases of the first mentioned variety are extremely 
rare. By proper legal restrictions regarding the production of vaccine 
virus they should be entirely eliminated. Its production should never be 
permitted in a district in which tetanus is endemic • and each quantity of 
lymph sent out should be tested for tetanus. In the great majority of 
the reported cases in which tetanus has followed vaccination the evidence 
is strong that infection occurred subsequent to vaccination, owing to want 
of proper care or insufficient protection of the vaccinated part. It should 
not be forgotten that vaccination produces an open wound, which may 
become infected like any other wound. The most common form of local 
infection is cellulitis, which may terminate in suppuration or sloughing 
at the |ite of vaccination, and sometimes may cause suppuration of the 
neighboring lymph nodes. Erysipelas may develop at any time before 



PERTUSSIS 1003 

the wound is entirely healed; it is usually due to neglect of proper pre- 
cautions in the care of the vaccine sore. 

The mortality of vaccination is stated by Voigt, from careful statistics 
drawn from German sources, to have been 35 in 2,275,000 cases, including 
both primary and secondary vaccinations. Of the deaths, 19 were due to 
erysipelas, 8 to gangrene, 2 to cellulitis, 3 to "blood poisoning," and 3 to 
other causes. Nearly all the deaths from vaccination are from causes 
which are preventable. 

Treatment. — The whole purpose of treatment is to prevent infection. 
The first essentials are a clean limb, pure virus, and a sterile needle ; the 
next, to allow thorough drying of the wound before the clothing touches 
it. After this no treatment is necessary until the vesicle forms. Then the 
important thing is to prevent scratching and the irritation by the cloth- 
ing. All vaccine shields are objectionable. For an infant nothing is 
better than the sterilized gauze bandage, which can be kept in place by 
sewing to the stocking or to the sleeve of the shirt. Any constriction of 
the limb is injurious. For older children the simplest dressing is a pad of 
sterile gauze fastened to the limb by two pieces of adhesive plaster. 
Should the vesicle rupture and discharge serum, it should be kept clean 
and dry by dusting daily with boric acid. When the local symptoms are 
at all severe the limb should be kept at rest. An infected vaccination 
wound, like any other infected wound, requires careful surgical treat- 
ment ; disastrous results often follow the use of poultices and other appli- 
cations much in vogue in domestic practice. 



CHAPTER VI 
PERTUSSIS 

( Whooping-Cough) 

Pertussis is a contagious disease which prevails epidemically and, 
in all large cities, endemically. Although it may affect persons of any 
age, it is generally seen in young children. While in later childhood 
pertussis may be ranked as one of the milder in feci ions diseases, in 
infancy it is one of the most fatal. Us principal complications are 
bronchopneumonia and convulsions. Pertussis is characterized by catar- 
rhal and nervous symptoms. The catarrh affects the mucous membrane 
of the respiratory tract, and is probably due to a specific form of infec- 
tion. Tt is accompanied by a hyperesthetic condition of this mucous 
membrane. The most prominent nervous manifestation is a peculiar 



1004 THE SPECIFIC INFECTIOUS DISEASES 

spasmodic cough which occurs in paroxysms, and from which the disease 
takes its name. The cough is no doubt of reflex origin, from an irrita- 
tion which has been located by different writers in various parts of the 
resp .'ratory tract. In addition to these conditions, there is present in 
pertussis a marked irritability of the nervous system, which in infancy 
often shows itself by convulsions. Whooping-cough is a disease whose 
importance is too often passed over lightly. In New York State it 
causes more deaths than scarlet fever and nearly as many as does typhoid 
fever. 

Etiology. — Present evidence points to the Bordet-Gengou bacillus 
as the specific organism of pertussis. It is a small Gram-negative bacillus 
which in many points resembles the influenza bacillus. It is difficult to 
obtain the organism from the respiratory secretion unless the plug of 
mucus brought up after the paroxysm of coughing is secured, as it 
develops chiefly in the lower respiratory tract. It is found only in the 
early stage of the disease, rarely later than a week after the whoop 
begins. Smears are unreliable for diagnosis ; only cultures are to be 
depended upon. In practically all cases there is mixed infection, cer- 
tainly after the first week or two. There may be associated the pneumo- 
coccus, the B. influenzae, the staphylococcus, or streptococcus. There are 
still lacking some elements of proof that the Bordet-Gengou bacillus is 
the cause of pertussis. Although it has been found in the great majority 
of cases examined by competent observers early in the disease, yet its 
absence in some typical cases cannot be explained. The results of com- 
plement fixation tests have not been uniform, but these may be due to 
differences in the strains of the organism. Finally there is evidence that 
other forms of infection of the respiratory tract may produce a group 
of symptoms which are clinically indistinguishable from true pertussis; 
i. e., a contagious catarrh and a paroxysmal cough with a duration of 
four to eight weeks. This we have repeatedly seen associated with the 
presence of the B. influenzae. 

Proximity to a patient seems all that is required to communicate the 
disease and even close proximity is not necessary. Czerny places the 
infective distance at about five feet from the patient. The disease seems 
to be spread chiefly by droplets diffused by coughing and sneezing. 

Predisposition. — Fully one-half the cases of pertussis occur during 
the first two years of life. The following are the statistics of Szabo 
(Buda-Pesth), showing the ages at which the disease was met with in 
4,591 cases, comprising the records of one clinic for thirty-four years: 

Under one year 1,028 cases Three to four years 904 cases 

One to two years 1,008 " Four to seven years 803 " 

Two to three years 659 " Over seven years 189 " 



PERTUSSIS 1005 

The susceptibility of young infants to pertussis is very great. To 
them unquestionably the disease may be carried by a third person. 
Many cases are on record in which pertussis has occurred during the 
first month, and one has come to our notice where a child twelve days 
old was attacked, whose mother was suffering from the disease. The 
disease is nearly twice as frequent in the winter and spring as in the 
summer and autumn. Epidemics of pertussis often occur at the same 
time with or follow those of measles. 

The susceptibility to pertussis is very great, and is equalled only by 
that to measles. Biedert reports that of 401 children exposed during 
an epidemic in a certain village, 366, or ninety-one per cent, took the 
disease. 

As a rule one attack protects the individual during his life. The 
great majority of the reported instances of second attacks are certainly 
to be explained by mistakes in diagnosis. These may be almost unavoid- 
able; for it is at times almost impossible to distinguish true pertussis 
from the paroxysmal cough which occurs in some cases of influenza. 

Infective Period. — Pertussis may be communicated from the very be- 
ginning of the catarrhal stage ; it is more contagious at this period than 
later. There seems little doubt that it is contagious throughout the 
spasmodic stage, but the infectivity of the disease after the first few 
weeks is slight. The recurrence of the whoop with a fresh cold, after it 
has once ceased, cannot be considered a relapse nor regarded as con- 
tagious. Quarantine is generally required for two months. The usual 
source of the contagion is the patient, rarely the room or the clothing. 

Incubation. — The very gradual onset of pertussis renders it impos- 
sible in the majority of cases to fix the exact date, and hence to estab- 
lish the definite duration of the period of incubation. In cases where 
this could best be determined it has usually been from seven to fourteen 
days, or about the same as in measles. If, after an exposure, sixteen 
days pass without the development of a cough, the probabilities are very 
strong that the disease has not been contracted. 

Lesions. — The only constant lesion of pertussis consists in a catarrhal 
inflammation of varying intensity, which affects the mucous membrane 
of the larynx, trachea, and bronchi, and sometimes that of the nose and 
pharynx. Mallory claims that the presence of the bacilli between the 
ciliae of the epithelial cells of the trachea and bronchi is the specific 
lesion. Others have found a similar condition in influenza. W the child 
dies during a paroxysm, either with or without convulsions, the brain is 
found intensely congested and may be the seat of punctate hemorrhages, 
or even larger extravasations. The lungs always show emphysema if 
the attack has been severe or protracted. The other pulmonary lesions 



1006 THE SPECIFIC INFECTIOUS DISEASES 

are due to complications, the most frequent of which is bronchopneu- 
monia. Catarrhal enteritis and colitis are not infrequent. 

Symptoms. — The symptoms of pertussis are usually divided into 
three stages — the catarrhal, the spasmodic, and the stage of decline. 

The catarrhal stage continues on the average for about ten days, 
although cases show considerable variation on this point. Some chil- 
dren whoop almost from the very beginning of the disease, while others 
may cough for three or four weeks before a typical whoop is noticed. 
The symptoms in the beginning are indistinguishable from those of an 
ordinary attack of subacute tracheobronchitis, and unless there has been 
an exposure to pertussis no suspicion is excited. After five or six days, 
however, the cough, instead of abating as in an ordinary cold, gradually 
increases in severity and occurs in paroxysms. At first these are mild, 
and there are only two or three a day, but they gradually increase in fre- 
quency and severity until the typical whoop is heard which marks the 
beginning of the spasmodic stage. During the first stage there may 
be symptoms of a mild grade of catarrhal inflammation of the nose, 
pharynx and larynx, and often there is a slight elevation of temperature. 

The Spasmodic Stage. — In a typical paroxysm of average severity the 
child, who can usually foretell it, will often run for support to the lap 
of the mother or the nurse, or seize a chair with both hands. There 
now occurs a series of explosive coughs, from ten to fifteen in number, 
coming in such rapid succession that the child can not get his breath 
between them; the face becomes a deep-red or purple color, sometimes 
almost black; the veins of the face and scalp stand out prominently; 
the eyes are suffused, and seem almost to start from their sockets ; there 
follows a long-drawn inspiration through the narrowed glottis, produc- 
ing the crowing sound known as the whoop ; and then another succession 
of rapid coughs follows and another whoop. In a single severe paroxysm, 
which lasts several minutes, the child may whoop half a dozen times; 
with the final paroxysm a mass of tenacious mucus is usually brought 
up. In a young child vomiting is almost certain to follow, if food 
has been recently taken. Epistaxis sometimes occurs with nearly 
every severe paroxysm, but in most cases the bleeding is slight. After 
a severe attack the child is at times so exhausted as to be hardly able to 
stand. There is profuse perspiration ; his mind is confused, and he may 
be completely dazed. In infants the attack may result in a degree of 
asphyxia requiring artificial respiration. Those old enough to describe 
their sensations tell of a sense of impending suffocation, the suffering 
from which is almost indescribable. 

The number of severe paroxysms or "kinks" in twenty-four hours 
varies, according to the severity of the case, from half a dozen to forty 



PERTUSSIS 1007 

or fifty. There are always many more of a milder form. Paroxysms 
are often excited by eating or drinking anything cold, by a draught of 
air, or by imitation; they are usually more frequent during the night 
than the day, and in a close room than in the open air. 

In less severe cases no paroxysms of the grade above described may 
occur, and no typical whoop may be heard throughout the attack; but 
the paroxysmal nature of the cough which continues until the plug of 
mucus is expelled, the watery eyes, and the vomiting which follows a 
paroxysm, stamp the disease as pertussis. In young infants the whoop 
is frequently not marked. The child sometimes coughs until he is as- 
phyxiated, and yet no whoop occurs. The paroxysms are also modified 
by intercurrent disease, especially by attacks of pneumonia or severe 
bronchitis. At such times they usually become less frequent and less 
typical, and may be absent for several days, returning as the complica- 
tion subsides. 

The seat of the irritation which produces the cough has been vari- 
ously located by different observers. Some have thought it to be in the 
nose, others in the trachea, the bronchi, or the larynx. It is very prob- 
able that it may not always be in the same place and that the infectious 
catarrh, which is really the most important element in the disease, may 
vary in its intensity and location in different cases. The weight of evi- 
dence seems to be that in the great majority of cases the source of irrita- 
tion is in the larynx or trachea. From laryngoscopic examinations made 
during the disease, Von Herff found the mucous membrane of the larynx 
to be swollen and congested, and occasionally the seat of small hemor- 
rhages or superficial ulcers. He states that the frequency and severity 
of the paroxysms corresponded with the degree of laryngitis, and he 
found that a paroxysm could always be excited by irritating the mucous 
membrane between the arytenoid cartilages. During a paroxysm he 
observed that there was a collection of mucus on the posterior laryngeal 
wall, the removal of which had the effect of shortening the paroxysm. 

Rossbach made laryngoscopic examinations, with negative results so 
far as the larynx was concerned, but he states that a plug of mucus could 
always be seen in the lower trachea for one or two minutes before the 
paroxysm occurred. There is little doubt that this collection of mucus 
is the exciting cause of the paroxysm, as it is a familiar clinical fact that 
the paroxysm continues until this is dislodged. 

The average duration of the spasmodic stage is about one month. 
It increases in intensity for the first two weeks, remains stationary for 
about a week, and then gradually diminishes in severity. The course and 
duration of tin's stage are, however, subject to wide variations. In mild 
cases it may last only a week; in severe cases, especially in the winter 



10 08 THE SPECIFIC INFECTIOUS DISEASES 

season, it may continue for three months, at times almost subsiding, but 
lighting up again with all its previous severity with every fresh catarrhal 
attack. After it has entirely ceased the whoop may return with an 
attack of bronchitis, and continue for a month or more. This is not to 
be regarded as a true relapse of pertussis. The habit of the paroxysmal 
cough once established, it tends to recur with every slight bronchitis, 
often for months afterward. 

The Stage of Decline. — Gradually the severity of the paroxysms 
abates, the whoop ceases, and the cough resembles more and more that 
of ordinary bronchitis. This stage usually continues about three weeks, 
but may be prolonged indefinitely in the winter months. 

Complications.r— Hemorrhages. — The hemorrhages of pertussis are 
mechanical, and depend upon the intense venous congestion which ac- 
companies the paroxysm. Epistaxis is the most frequent variety, and 
occurs in a considerable proportion of the severe cases, in a few with 
almost every severe paroxysm, but it is rarely severe enough to require 
local treatment. Hemorrhages from the mouth may have their origin 
either in the pharynx or the bronchi, the blood being brought up by 
the cough; such hemorrhages are usually small. Conjunctival hemor- 
rhages are less frequent, and are usually slight, although we have seen 
the entire conjunctiva covered. In a case under our observation there 
was bleeding from both ears with every severe paroxysm for more than 
a week. This child had previously suffered from scarlatinal otitis, with 
perforation of the drum membrane. Small extravasations into the cellu- 
lar tissue beneath the eyes are occasionally seen, giving an appearance 
somewhat like an ordinary "black eye." Intracranial hemorrhages are 
not frequent, but many examples have been recorded, and they may 
be severe enough to produce death. They are usually meningeal, very 
rarely cerebral ; according to their extent and location they may produce 
hemiplegia, monoplegia, aphasia, facial paralysis, or disturbances of 
sight, hearing, or sensation; in addition, there may be convulsions or 
rigidity, but rarely complete coma. The extravasations are sometimes 
small and the symptoms which they produce may disappear at the end 
of a few weeks. More extensive hemorrhages cause serious results. In 
almost every instance these hemorrhages have occurred as a direct result 
of the severe paroxysms. Purpura hemorrhagica is occasionally seen 
as a sequel of pertussis. 

Respiratory System. — The most serious complications of pertussis are 
connected with the lungs. By far the largest proportion of deaths is 
due to pulmonary complications, usually bronchopneumonia. This is 
more frequent in winter and spring than in the summer months, and is 
especially to be dreaded during infancy. In later childhood lobar pneu- 



PERTUSSIS 1009 

moiiia is occasionally seen. Pneumonia rarely begins before the second 
week of the disease, and most frequently develops at the height or toward 
the close of the spasmodic stage. The physical signs present no peculiar- 
ities; the cough changes somewhat in character during the pneumonia, 
and the whoop may not be heard. The prognosis of the pneumonia is 
bad, because of the debilitated condition of the children at the time of 
its occurrence. A great danger is from the supervention of convulsions, 
this being a frequent mode of termination. As there is always consider- 
able emphysema, the rapidity of breathing is frequently out of proportion 
to the temperature, which often is only moderately elevated. If the child 
escapes the dangers of the acute stage, death may still occur from ex- 
haustion, owing to the protracted course which the disease frequently 
runs. 

Bronchitis of the large tubes is present in almost all the severe cases, 
and is not of itself serious. Bronchitis of the small tubes has the same 
dangers and the same complications as bronchopneumonia. 

Vesicular emphysema is invariably present in every case of pertussis 
which comes to autopsy. A certain amount of it certainly occurs in 
every severe case. It is produced by the forcible cough of the paroxysm. 
In very severe cases interstitial emphysema is also found. Rupture of 
the air-blebs which form on the surface of the lung may lead to em- 
physema of the cellular tissue of the mediastinum, and the air may find 
its way along the great vessels into the neck, and finally into the subcu- 
taneous cellular tissue of the entire body. Cases of general subcutaneous 
emphysema have been reported by Croker and by Hodge, both of which 
ended fatally, one in three and one in eight days from the beginning of 
the emphysema. In the great majority of the cases vesicular emphysema 
is not permanent. 

Digestive System. — During the summer, infants with pertussis are 
almost certain to suffer from diarrhea; it may be only an occasional 
symptom, or the attack may be severe and prolonged, resulting in the 
development of ileocolitis. The intestinal complications may be almost 
as serious in summer as are those of the respiratory tract in winter. 
Vomiting is even more frequent than diarrhea, and while it may be dis- 
tressing at any age, it is especially so in infancy. So frequently does the 
taking of food excite vomiting, that the nutrition of these patients often 
hecomes a matter of the greatest difficulty, and in fact the most serious 
problem in the management of a case. Malnutrition and even marasmus 
may follow, or the general resistance of the child may become so reduced 
by lack of food that he falls a ready prey to pneumonia. 

Nervous System. — There may he convulsions, coma, paralysis. 
aphasia, disturbances of sight or hearing, and in rare cases even the 



1010 THE SPECIFIC INFECTIOUS DISEASES 

mental condition may be affected. The most serious of these complica- 
tions are convulsions. They are much more frequent in infancy than 
later, and particularly in those who are rachitic, in whom they are often 
fatal. Convulsions are of course more common in severe attacks, but they 
may occur suddenly when there has previously been no cause for 
anxiety. They are especially to be dreaded if pneumonia is present. 
The attack of convulsions may be the culmination of the extreme degree 
of nervous irritability which accompanies the paroxysm, it may be due 
to asphyxia, or to an intracranial lesion; if the latter, there is usually 
meningeal hemorrhage. This is to be suspected if there are continued 
convulsions for several hours, with general rigidity or hemiplegia. 

Disturbances of sight are not infrequent in severe cases; usually 
these are transient, but there may be blindness lasting two or three days 
or even weeks. The transient symptoms depend most likely upon cir- 
culatory changes that occur in the brain during the paroxysm, while 
those which last for two or three weeks are probably due to meningeal 
hemorrhage. Disturbances of hearing are rare. The different forms 
of paralysis occurring with pertussis may likewise be transient or per- 
manent. They are to be explained in the same way as the disturbances 
of the special senses. The most common form is hemiplegia. 

Albuminuria is not infrequent, being found in sixty-eight of eighty- 
six examinations by Knight. The quantity of albumin is rarely large, 
and it may be accompanied by a few hyaline casts. Both are probably 
the result of circulatory disturbances in the kidney. Other complica- 
tions of pertussis are hernia, prolapsus ani, and ulcer of the frenum 
linguae. 

Diagnosis. — The only constant features of pertussis are the course of 
the disease and its communicability. In many cases the typical whoop 
is never heard. There are no symptoms by which a positive diagnosis 
can be made in the catarrhal stage; but a cough not accompanied by 
fever or physical signs, which steadily increases in severity for two weeks, 
in spite of treatment, and which occurs chiefly at night, is always suspi- 
cious. When, in addition, the cough begins to come in paroxysms, ac- 
companied by suffusion of the face and occasionally by vomiting, there 
can be little doubt even though no whoop is heard. If the disease is 
prevalent the diagnosis is practically certain. Mild cases which do not 
go even as far as the symptoms mentioned are most puzzling. But if 
there is a history of exposure, if the cough continues from four to six 
weeks, little influenced by treatment, and if other typical cases follow, the 
disease must be pertussis. Without evidence of communicability, how- 
ever, one may be in doubt even after the disease is over. In certain cases 
of influenza there may be a paroxysmal cough which by its symptoms 



PERTUSSIS 1011 

and course can not be distinguished from pertussis, I at which may be 
recognized by an examination of the blood and sputum (vide Influenza). 

In early infancy any cough may have more or less of a spasmodic 
character, and a fairly typical whoop is often heard in the course of an 
ordinary bronchitis. We have several times seen abortive or very short 
attacks in one member of a family of children, the others having the dis- 
ease in a typical form. Occurring by themselves such cases can not be 
recognized. 

Irritation of the pneumogastric or recurrent laryngeal nerve from 
tuberculous tracheal or bronchial lymph nodes, or from a foreign body 
in the air passages, may give rise to a spasmodic cough, which in certain 
cases may be indistinguishable from pertussis. The prolonged duration 
of the symptoms is sometimes the only diagnostic point; but the par- 
oxysms are usually not so severe as in true pertussis, and the course is 
generally less typical. 

The blood examination is of much assistance in diagnosis. The 
leucocytosis accompanying pertussis far exceeds that of any other afebrile 
disease of the respiratory tract. It appears in the early part of the con- 
vulsive stage, and disappears slowly with improvement. The total 
count is usually between 15,000 and 30,000, although it* may reach 
50,000. There is a great increase in the lymphocytes at the expense of 
the polymorphonuclear neutrophiles. The lymphocytes may form 60 
to 80 per cent of the total leucocytes. The leucocytosis is little influenced 
by complications, and even during bronchopneumonia the lymphocytes 
may continue to be in excess. 

Prognosis. — The most important factor in the prognosis of the dis- 
ease is the age of the patient. After the fourth year it is indeed rare 
that either a fatal result or serious complications are seen; but during 
infancy, and particularly during the first year, there are few diseases 
more to be dreaded. This is especially true on account of the connection 
of whooping-cough with the three most fatal conditions of infancy 
— bronchopneumonia, diarrheal diseases, and convulsions. Fully two- 
thirds of the deaths from whooping-cough occur during the first year of 
life. The prognosis is very much worse in infants under three months 
than in those who are older and consequently have more resistance. It 
is better in the summer than in the winter, because bronchopneumonia 
is then less frequent. It is particularly bad in delicate infants, in those 
who are rachitic, in those who are prone to attacks of bronchitis, in 
those who have suffered previously from pneumonia, and in those with 
a strong tendency to tuberculosis. 

The exact mortality of whooping-cough it is difficult to state in fig- 
ures. During the first year of life it is probably no! far from twenty-five 



1012 THE SPECIFIC INFECTIOUS DISEASES 

per cent, although it diminishes rapidly after this time. In foundling 
asylums and hospitals for infants it is to be ranked among the most 
fatal diseases, and in some epidemics the mortality in such institutions 
is as high as fifty per cent. 

Fully two-thirds of the deaths during whooping-cough are from 
bronchopneumonia; the next most frequent cause is diarrheal diseases. 
Convulsions may be the mode of death in either of the above conditions, 
or may occur apart from them. During the first year, death often results 
from marasmus, the child having been reduced by the prolonged disease. 
Occasionally death is due to asphyxia following a severe paroxysm, to 
intracranial hemorrhage, or to general emphysema. 

As a predisposing cause of generalized tuberculosis, pertussis is sec- 
ond only to measles. In both diseases tuberculosis develops in much the 
same way and from practically the same causes. 

Prophylaxis. — Pertussis is a contagious disease, and a child suffering 
from it should be isolated from other children whenever this is possible. 
Children with pertussis should never be allowed to attend school, and 
needless exposure should always be avoided. 

Young infants, delicate children, and those with a predisposition to 
tuberculosis, should be most carefully protected against exposure, since 
it is in them chiefly that the disease is likely to be serious. As it is 
from the patient that the disease is nearly always contracted, there 
does not exist the same necessity for the careful disinfection of apart- 
ments as after other contagious diseases. In institutions, however, 
this should always be practiced, and in private houses if the room is 
subsequently to be occupied by an infant. The prophylactic use of 
vaccines is referred to under Treatment. 

It is as undesirable as it is impossible to confine a child with per- 
tussis to a single room during the attack; all those persons for whom 
exposure would be dangerous should therefore be sent away from the 
house. Quarantine should continue for at least six weeks, or until the 
spasmodic stage is over. 

Treatment. — We have as yet no specific remedy for pertussis. The 
important thing in most cases is the hygiene or general management of 
the case; fully half of the cases seen in practice require nothing more. 
Much harm is done by indiscriminate drug giving. 

General Measures. — Fresh air is important throughout the attack. 
It is almost invariable that the paroxysms are fewer while patients are 
out of doors, and more frequent when they are in close rooms. Older 
children with pertussis may go out even in winter except on stormy, raw, 
or windy days. With infants and delicate children, however, the outdoor 
treatment in cold weather so enthusiastically advocated by some writers 
should be used with the greatest caution. It should not be permitted 



PERTUSSIS 1013 

if the patient has even the slightest amount of bronchitis. Our experi- 
ence is that during the winter in a climate like that of New York or 
New England, the class of patients just referred to are better off indoors, 
taking their airing in their rooms. In warm weather or in a mild 
climate all children should be kept in the open air as much as possible. 

A change of climate is desirable when the cough is unduly prolonged, 
also for delicate children in winter. A warm place at the seashore is 
one which is most likely to be beneficial. The improvement following a 
sea voyage is often very marked, surpassing even a residence at the sea- 
shore. 

The rooms occupied by children suffering from pertussis should be 
frequently changed, thoroughly aired and cleaned. A change of rooms, 
clothing, bedding, etc., sometimes exerts a marked influence on the course 
of very prolonged attacks, the inference being that continued re-mfection 
takes place. Such a change should be made twice a week, and it is of 
special importance in hospitals, where many children quarantined in a 
single ward seem to cough interminably. 

Careful feeding and attention to the bowels are matters of the 
greatest importance; with infants particularly, chronic indigestion and 
abdominal distention have a very marked effect in increasing the fre- 
quency of the paroxysms. The abdominal support furnished by a snugly 
fitting band, adds materially to the comfort of the patient in a severe 
attack. Feeding is difficult since vomiting occurs so easily. In most 
cases it is necessary to repeat the meal in a short time, if the first one 
has been vomited. Children over two years old should in all such cases 
be kept largely upon a fluid diet ; the meals should be smaller and more 
frequent than in health. For infants, milk should be modified according 
to the child's digestive symptoms. Any medication which causes dis- 
turbance of the stomach should be omitted. 

Local applications to the rhinopharynx or to the larynx by means of 
a spray or swab have been advocated by many. We have never seen the 
beneficial results claimed, and believe them to be exaggerated. The 
application of cocain to the larynx should under no circumstances be em- 
ployed in young children. 

Inhalations are of much more value. They are useful to modify the 
catarrh by allaying irritation, facilitating the expulsion of the mucus, 
and possibly as antiseptics. Those most employed are creosote and cres- 
olene. In our experience creosote is the hot. These substances may he 
used upon cotton in a respirator, or vaporized over an alcohol lamp. The 
possibility of absorption should not be forgotten, and the urine should be 
watched. When the paroxysms are frequent and of great severity, chloro- 
form may be used to ward off convulsions or prevent dangerous asphyxia. 
In such conditions O'Dwyer used intubation with striking benefit. The 



1014 THE SPECIFIC INFECTIOUS DISEASES 

tube entirely overcomes the glottic spasm which is the chief cause of 
suffering and danger. 

Internal Medication. — Of the innumerable drugs which have been 
recommended for this disease, there are two which possess undoubted 
advantages over all others, viz., belladonna and antipyrin. In giving 
belladonna it is important to begin with a small dose and cautiously in- 
crease both its frequency and size. To an infant two years old, one- 
fourth of a minim of the fluid extract may be given every four hours as 
an initial dose, gradually increasing to every two hours; if atropin is 
used, gr. 1-800 may be given in the same way. Although belladonna 
usually has a decided influence in reducing both the frequency and the 
severity of the paroxysms, it causes many unpleasant symptoms, and its 
effects must be closely watched. 

Antipyrin has been in our experience more generally useful than 
any other single drug. It may be given with safety, even to young in- 
fants, in considerably larger doses than are ordinarily employed. For a 
child six months old the initial dose may be one grain every three hours ; 
later this may be given every two hours. For a child two years old the 
initial dose may be two grains repeated every four to six hours, gradually 
increasing up to two grains every two hours. Should pneumonia develop, 
the antipyrin should be discontinued. A combination of the bromid of 
sodium with antipyrin is often better than the latter given alone. 

Nearly all drugs which allay nervous irritability have a certain 
amount of effect in controlling the paroxysms of pertussis; codein, 
chloral, and trional are useful where the night attacks are so severe as to 
prevent sleep. We do not believe that any form of internal medication 
or local treatment shortens pertussis; but, inasmuch as the disease is 
self -limited, great benefit to the patient results from the reduction of the 
number and the diminution of the severity of the paroxysms. 

Vaccines have been much employed in the treatment of pertussis dur- 
ing recent years with exceedingly variable results. Vaccines made from 
stock cultures of the Bordet-Gengou bacillus have been most widely 
used. Several facts militate against success by this treatment: first, 
our uncertainty regarding the bacterial cause. While the Bordet-Gen- 
gou bacillus has been altogether most frequently found, a paroxysmal 
cough which clinically is indistinguishable from pertussis may be asso- 
ciated with the different forms of so-called hemoglobinophilic bacteria. 
In the second place there are apparently several distinct strains of the 
Bordet bacillus. The evidence as to curative value of vaccines is as yet 
inconclusive. There is somewhat more evidence that they are useful as 
a means of prophylaxis ; but this point is by no means established. How- 
ever, inasmuch as they are harmless the use of vaccines is advisable as 
;i preventive measure in the case of young infants exposed. The question 



MUMPS 1015 

of therapeutic dosage is still unsettled; from 25 to 100 millions, accord- 
ing to the age of the child, repeated every two to four days is at present 
to be advised. For prophylaxis full doses are also needed ; they should be 
repeated for three or four doses at intervals of five or six days. 

In establishing the value of any method of treatment, it should be re- 
membered that the number of cases in which the duration of the disease 
is short is quite large, and also that almost any method of treatment if 
employed after the attack has reached its height will be thought beneficial, 
as the natural tendency is then to improve. The value of any particular 
line of treatment is to be judged in a given case only by its effect in 
reducing the number and severity of the paroxysms. This ought to be 
evident in the case of drugs or vaccines within a few days, and can only 
be determined by keeping a careful record of the number of severe 
paroxysms day and night. 

In a mild case, when the number of paroxysms does not exceed eight 
or ten during the day, when there is no vomiting and the general health 
ig not affected, it is not usually advisable to continue the administra- 
tion of any drug throughout the disease. A single dose of antipyrin 
or codein at night may be all that is necessary. All cases in infants 
must be watched with great care and the parents warned of the possible 
dangers which may supervene suddenly, even in the course of mild 
attacks. For severe eases antipyrin should be given to diminish the 
frequency and the severity of the paroxysms, and inhalations of creosote 
used if much catarrh is present. All the fresh air possible should be 
allowed, but without exercise. For older children the same plan of treat- 
ment may be followed, or quinin or belladonna may be substituted for the 
antipyrin. 

As these drugs are given solely for the purpose of diminishing the 
frequency and severity of the paroxysms, their continuous use should 
be deferred until the symptoms are sufficiently severe to greatly disturb 
the child, the benefit at this period being more striking than if they are 
begun early and used continuously. 



CHAPTER VII 

MUMPS 

(Epidemic Parotitis) 



Mumps is a contagious disease characterized by swelling of the par- 
otid, and sometimes of the other salivary glands, with constitutional 
symptoms which are usually mild. Both severe complications and a 



1016 THE SPECIFIC INFECTIOUS DISEASES 

fatal termination are extremely infrequent. The disease is not a very 
common one, and general epidemics are not common. 

Pathology and Lesions. — The contagious character, regular incuba- 
tion period and typical course, stamp the disease as a general one due to a 
specific organism, but this has not been definitely determined. Unques- 
tionably the virus is present in the saliva of affected persons and in all 
probability the poison is eliminated by Steno's duct. By inoculating the 
saliva from patients with mumps into the parotid gland of cats, Woll- 
stein has reproduced a similar disease in these animals with typical 
symptoms and transferred this again to other animals with the produc- 
tion of the same symptoms. It has long been a popular tradition that 
domestic cats were occasionally the subjects of mumps. 

The precise nature of the changes in the gland is still a matter of 
dispute, as opportunities for pathological examination are very rare. 
From existing evidence it would appear that the gland substance is first 
involved, and afterward the surrounding connective tissue. The gland 
is the seat of an intense hyperemia and edema; the walls of the salivary 
ducts are swollen, and the ducts are obstructed. While the primary dis- 
ease does not tend to excite suppuration, pyogenic germs may occasionally 
gain entrance and an abscess form; but this is to be regarded as a rare 
accidental infection. 

In the great proportion of cases the parotids alone are affected, al- 
though the same changes are occasionally found in the other salivary 
glands. There are no other essential lesions of the disease, those which 
are found depending upon complications. 

Etiology. — Mumps is spread by contagion, close contact being usually 
required to communicate the disease, although it is known to have been 
carried by a third person and even by clothing. The susceptibility of 
children to the poison of mumps is much less than is the case with the 
other contagious diseases, so that only a small number of those who are 
exposed take the disease. The greatest predisposition is between the 
fourth and fourteenth years. Infants are rarely affected, although a 
case in a child three weeks old is vouched for by so good an observer as 
Demme. 

Mumps is contagious from the beginning of the symptoms. Two 
cases have come under our notice in which the disease was communicated 
before any swelling was seen. It is impossible to fix with certainty the 
duration of the infective period. The disease is undoubtedly communi- 
cable for a few days after the swelling has subsided; and for safety a 
case should be isolated for three weeks from the beginning of symptoms, 
or one week after the swelling has disappeared. 

Incubation. — In forty-eight collected cases in which the incuba- 
tion was definitely determined, it varied between three and twenty-five 






MUMPS 1017 

days. It was less than fourteen days in only four cases, and in twenty-six 
of the forty-eight cases it was between seventeen and twenty days. In 
three cases of our own in which it could be definitely fixed, the incubation 
was nineteen days in one case and twenty days in two cases. The average 
period of incubation, then, may be stated to be from seventeen to twenty 
days. 

Symptoms. — In the milder cases the local symptoms are the first to 
attract attention; in those which are more severe there are frequently 
prodromal symptoms of from twelve to forty-eight hours' duration — 
anorexia, headache, vomiting, pains in the back and limbs, and fever. 
Soltmann has reported a case ushered in by convulsions. The initial 
temperature in a mild attack is 100° to 101° F. ; in a severe one, from 
102° to 104° F. 

Of the local symptoms, the pain usually precedes the swelling; it is 
increased by movement of the jaws, by pressure, and sometimes by the 
presence of acid substances in the mouth. It is usually referred to the 
posterior part of the jaw just below the ear. The swelling may begin 
simultaneously in both parotids, but more frequently one side is involved 
a day or two in advance of the other. It usually reaches its maximum on 
the third day, remains stationary for two or three days, and then sub- 
sides gradually. The degree of swelling varies with the severity of the 
attack. When it is marked, the patient may be so changed in appear- 
ance as scarcely to be recognizable. The swelling fills the lateral region 
of the neck between the jaw and the sternomastoid muscle and extends 
forward upon the face to the zygomatic arch, so that the center of 
the tumor is usually the lobe of the ear. The other salivary glands 
may swell simultaneously with the parotids, or several days later, even 
after the parotid tumor has disappeared. Occasionally swelling of the 
submaxillary or the sublingual glands occurs before that of the parotid, 
h ud in rare instances these may be the only glands affected. 

As a rule, the parotid of each side is involved. Of 282 cases both 
sides were affected in 215. When one side alone is involved, it is the 
left a little more frequently than the right. The interval between the 
swelling of the two sides may be a week, or even five or six weeks, but 
usually it is only two or three days. 

The salivary secretion is usually very much diminished, and the dry 
mouth causes great discomfort. Exceptionally, distressing salivation 
occurs, the secretion amounting to six or eight ounces daily. 

Although as a rule the patient is not seriously ill, mumps may in 
rare cases produce most alarming and even dangerous symptoms. The 
temperature may for several days reach 104° F. or more, deglutition may 
be extremely difficult, pressure on the jugular veins may lead to venous 
hyperemia of the brain, causing headache and sometimes delirium ; there 



1018 THE SPECIFIC INFECTIOUS DISEASES 

is sometimes great prostration and the symptoms of the typhoid condi- 
tion. These severe attacks are nearly always in patients over twelve 
years old. 

The constitutional symptoms of mumps usually last from three to 
five days; the swelling continues on an average about a week. If the 
case has been a severe one, slight swelling may continue for two weeks 
or even longer. Belapses, in which the opposite side from the one first 
affected is involved, are quite frequent, occurring in about ten per cent 
of the cases. 

The blood findings in mumps are quite characteristic. The total 
leucocytes vary considerably ; they may be normal or there may be a leu- 
copehia throughout the disease. There is a constant reduction in the 
polymorjihonuclears and an actual and relative increase in the lympho- 
cytes. 

Complications and Sequelae. — In childhood the complications are few 
and usually unimportant; but in adolescence they are occasionally seri- 
ous. Orchitis is exceedingly rare in childhood; of 230 cases observed 
by Eilliet and Barthez, this was seen in but ten, and only three of these 
cases were in children under fifteen years, and no case in one under 
twelve years old. When orchitis occurs it is generally toward the end 
of the second or the beginning of the third week; it is usually marked 
by an accession of fever, sometimes by a chill; if severe, nervous symp- 
toms may be present. The body of the testicle and not the epididymis 
is generally affected. The acute symptoms continue for three or four 
days, and the entire duration of the attack is about a week ; although the 
testicle is often enlarged for some time afterward, and atrophy of the 
organ may follow. When orchitis is double, sterility may be the con- 
sequence. 

In females, congestion and swelling of the breasts, ovaries, or labia 
majora may occur; and, although these complications are all very rare, 
most of them have been observed even in young children. The inter- 
relation between the parotids and the sexual glands has not yet received 
a satisfactory explanation. 

Nephritis has in a few instances followed mumps, sometimes coming 
on as late as four or five weeks after the attack. Single cases have been 
reported by Croner, Isham, Henoch, and others. Nervous sequelae are 
more frequent, but even these are rare. We have seen multiple neuritis 
in a boy of twelve which developed two weeks after a severe attack of 
mumps. The paralysis was general, lasted for six weeks, and was fol- 
lowed by complete recovery. Jaffrey has reported a similar case. Facial 
paralysis three weeks after mumps has been reported by Hillier, appar- 
ently due to an extension of inflammation from the gland to the seventh 
nerve. Meningitis may occur as a complication of mumps. We have 






MUMPS 1019 

seen one such case accompanied by high fever, delirium, opisthotonus, 
and a turbid cerebrospinal fluid containing a great many polymorphonu- 
clear cells. It was, however, sterile. The child recovered after five 
days' illness. 

Pearce has collected an interesting series of forty cases of deafness 
following mumps, in which there was no sign of otitis, the symptoms 
coming on suddenly with vertigo, a staggering gait, and often with 
vomiting. In most of the cases the deafness was unilateral and the loss 
of hearing was permanent. The cause assigned was disease of the au- 
ditory nerve, the seat of the trouble being in the labyrinth. Toynbee 
has reported an instance of hemorrhage into the labyrinth. Otitis media 
is rarely seen. 

Suppuration of the parotid gland occurs in about one per cent of the 
cases, and is probably due to accidental infection. Gangrene and slough- 
ing of the parotid were observed twice by Demme in 117 cases; both of 
these proved fatal. Pneumonia, meningitis, endocarditis, and pericar- 
ditis have been observed as complications of mumps, although all are 
extremely rare. 

Prognosis. — In the great proportion of cases mumps is a mild dis- 
ease, and terminates in complete recovery in a few days. In young 
children complications are infrequent, and those which occur are rarely 
severe. 

Diagnosis. — Mumps is most likely to be confounded with acute swell- 
ing of the cervical lymph nodes. In a parotid swelling, the lobe of the 
ear is near the center of the tumor, which extends backward to the 
sternomastoid muscle and forward upon the face as far as the zygomatic 
arch, embracing the angle and ramus of the jaw. 

A swollen lymph node is usually entirely below the ear and behind 
the jaw, not extending upon the face. The tumor is generally smaller 
and more circumscribed if only a single node is involved, and it comes 
on much more slowly than does mumps. When only the submaxillary 
or sublingual glands are affected, the diagnosis from swollen lymph nodes 
is sometimes impossible except by the course of the disease. Mumps is 
characterized by the rapidity with which the swelling occurs, and by its 
relatively short duration. 

Treatment. — The disease is self-limited and the individual symptoms 
rarely distressing, so that in most cases very little treatment is required. 
If constitutional symptoms are present the patient should be kept in 
bed, and if there are none he should be confined to the house. The gland 
should be protected by flannel or absorbent cotton, and if the pain is 
severe heat should be applied. The diet should be liquid, on account of 
the pain produced by mastication. The mouth should be kept clean by 
the use of some antiseptic mouth-wash. The general symptoms and com- 



1020 THE SPECIFIC INFECTIOUS DISEASES 

plications are to be treated according to the indications presented. Cases 
of mumps occurring in schools or institutions should be quarantined for 
three weeks, and in private practice where there are susceptible persons. 
Fumigation and disinfection after an attack are unnecessary. 



CHAPTER VIII 
DIPHTHERIA 

Diphthebia is an acute, specific, communicable disease due to the 
bacillus of Klebs and Loeffler. It is usually characterized by the forma- 
tion of a false membrane upon certain mucous membranes, especially 
those of the tonsils, pharynx, nose, or larynx. Like other pathogenic 
organisms, however, this germ acts with varying intensity, and may 
cause inflammation of all degrees of severity, from a mild catarrhal 
angina to the most serious membranous inflammation; but to all alike 
the term diphtheria should be applied. In its mild form it may be 
almost without constitutional symptoms; but in its severe form it is 
attended by great general prostration, cardiac depression, and anemia; 
it fe frequently complicated by pneumonia and nephritis, and it may be 
followed by localized or general paralysis; it then constitutes one of the 
diseases most to be dreaded in childhood. 

Etiology. — The Bacillus Diphtheriae. — This was first described by 
Klebs in 1883, and during the following year it was isolated by Loeffler 
and shown to be pathogenic. It is a Gram-positive bacillus and varies 
considerably in size and shape even in the same culture. In a specimen 
it occurs singly or in pairs, sometimes in chains of three or four; the 
bacilli may lie parallel, but frequently two form an acute or an obtuse 
angle. They are straight or slightly curved, and sometimes branching; 
they may be swollen or club-shaped at their ends. 

Distribution and Mode of Communication. — In most large cities 
diphtheria prevails endemically, with periods in which outbreaks of con- 
siderable severity are observed. In the country it prevails chiefly as an 
epidemic. The disease is often introduced into remote districts in sonu 
inexplicable manner, and before its nature is recognized a large number 
of persons may be exposed, and an epidemic results. 

Diphtheria does not arise de novo. Every case has its origin in a 
previous case either directly or remotely. The bacilli may enter the 
body through the inspired air; they may be taken into the mouth with 
toys or other articles upon which they have lodged, or by kissing, and 



DIPHTHERIA 1021 

sometimes by accidental inoculation. As a rule, the bacilli first gain a 
foothold upon the mucous membrane of the tonsils, nose, or larynx. 

Direct infection is the cause in the great majority of the cases. There 
is no proof that the bacilli are contained in the breath of a person suf- 
fering from the disease. They are present in great numbers in the saliva 
and mucus from the mouth and nose, often being distributed by sneezing, 
coughing, or even by talking. They are contained in pieces of membrane 
which are discharged ; they are not present in the feces. In rare instances 
they have been found in the urine but in such small numbers as to make 
it very improbable that this is an important source of infection. The 
most contagious cases are those of pharyngeal diphtheria on account of 
the amount of discharge which accompanies them. The least contagious 
are those in which the membrane is limited to the larynx and lower air 
passages. 

Direct infection may occur from persons convalescent from diph- 
theria, whose throats still contain virulent bacilli, or from persons suf- 
fering from a mild form of the disease, which is not recognized as diph- 
theria. In the latter way it is often spread in schools. It has been 
repeatedly shown that a person may harbor virulent bacilli in his nose or 
throat, and may even communicate the disease to others, without himself 
suffering from diphtheria at any time. Such persons are known as "car- 
riers" and are responsible for spreading the disease to many persons. 

The length of time during which a patient with diphtheria may con- 
vey the disease to others is somewhat uncertain. Transmission is possi- 
ble so long as virulent bacilli remain in the throat; these are frequently 
found two weeks after the membrane has disappeared and the patient is 
regarded as entirely well, and in a few cases they are found for many 
months after recovery. 

Indirect infection is uncommon. It may occur from dishes, feeding- 
bottles, or drinking-cups, from swabs and brushes used for local applica- 
tions to the throat ; from spoons and tongue-depressors, and from surgical 
instruments with which tracheotomy or intubation has been done. It is 
undoubtedly very unusual for infection to occur from the bed or cloth- 
ing of a patient, from carpets, toys, books, etc. Diphtheria may be car- 
ried by a third person but rarely, except by one who has been in close 
contact with the patient — either the physician or nurse — and has not 
taken sufficient precautions. The frequency of diphtheria in physicians' 
families bears witness to the danger of infection in this manner. 

Bacilli may retain their virulence for an indefinite period. Both 
Park and Loeffler have found cultures in blood-serum to be virulent after 
seven months; Roux and Yersin, bacilli in dried membrane to be virulent 
after twenty weeks, and Abel, upon a child's toy after five months. 

Domestic animals may in rare instances be carriers of infection, and, 
34 



1022 THE SPECIFIC INFECTIOUS DISEASES 

in the case of pigeons at least, they may themselves suffer from the 
disease. Diphtheria has been repeatedly spread by milk, but very rarely 
through the contamination of a water supply. 

Predisposing Causes. — Local conditions in the throat influence largely 
the Occurrence of diphtheria. An important predisposing cause is the 
existence of a chronic catarrhal inflammation of the mucous membranes 
of the nose and throat, frequently found in children suffering from ade- 
noid growths of the pharynx or from enlarged tonsils. These adenoid 
growths, the tonsillar crypts, and the cavities of carious teeth may harbor 
the bacilli for a considerable time both before and after an attack. The 
condition of the mucous membranes of the nose and pharynx in other 
acute infectious diseases furnishes a marked predisposition to diphtheria. 
This is most striking in the case of measles and scarlet fever. While 
diphtheria is seen throughout the year, it is more frequent during the 
cold than the warm months. 

Immunity. — The most important factor which determines if a per- 
son who has been exposed is to contract the disease is the presence or 
absence of immunity. Schick has shown by means of his test (described 
later) that many persons who have never had diphtheria or received 
antitoxin, already have antitoxin, or a substance similar to it, in their 
blood. Those who possess this natural antitoxin are immune to the dis- 
ease, and even though they may harbor virulent diphtheria bacilli in the 
throat or nose, they never show any clinical evidences of the disease. This 
natural antitoxin is possessed by most newly-born infants, only about 
7 per cent being without it. Infants gradually lose their immunity; 
at the end of the first year about 40 per cent, and by the second or third 
year fully 60 per cent, have lost it altogether and are consequently sus- 
ceptible to the disease. After four years the incidence of natural anti- 
toxin slowly increases so that at the age of ten or twelve years, only about 
25 per cent of children are without protection. These figures, obtained 
by combining those of Schick and Park, are in accordance with clinical 
experience. Very few newly-born infants acquire diphtheria, but the 
number of susceptible children steadily increases with age until about 
the third year, when it declines. Children from two to six years of age 
make up the majority of patients in diphtheria hospitals. Those persons 
who after the first year possess an immunity probably always retain it ; 
while those who at ten years of age do not possess an immunity probably 
will never acquire it. There is no difference in the sexes in this respect. 

The immunity conferred by one attack of diphtheria is not of long 
duration, amounting probably to a few weeks or months only; the passive 
immunity conferred by antitoxin is still shorter, lasting but a few days 
or weeks. Even in patients, therefore, to whom antitoxin has been given, 
a second attack may occur after a brief interval. 



DIPHTHERIA 



1023 



The incubation of diphtheria is short. In most of the cases in which 
it could be definitely traced it has been between two and five days. The 
virulence of the bacillus varies much in different cases and in different 
seasons, and while it is frequently true that persons infected from a mild 
type of the disease have a mild attack, and those infected from a malig- 
nant case a severe attack, there is no certainty that such will be the 
sequence. Park states that, out of many hundreds tested in the labora- 
tory of the New York Health Department, by far the most virulent 
bacillus was obtained from the throat of a boy who had what was clinic- 
ally a very mild form of tonsillar diphtheria. 

Lesions. — The essential lesions of diphtheria consist not in the pro- 
duction of a membrane, but, as long ago pointed out by Oertel, in cer- 
tain acute degenerative changes in the cells of the body caused by the 
diphtheria toxins. These changes are seen particularly in the epithelial 
cells of the affected mucous membranes, the heart muscle, the kidney, 
the liver, the central and peripheral nervous system, the spleen, and the 
lymph nodes. There are other lesions which are the result of the action 
of other organisms, especially the streptococcus pyogenes and the pneu- 
mococcus, either alone, together, or in conjunction with the diphtheria 
bacillus. The most important lesions due to these organisms are broncho- 
pneumonia and nephritis ; but there may be found in the blood, and in 
many of the organs of the body, the evidences of the invasion of these 
bacteria, i. e., a streptococcus septicemia, less frequently a general pneu- 
mococcus infection. 

Distribution of the Diphtheria Bacillus in the Body. — Unlike many 
other pathogenic organisms, the diphtheria bacillus is not in most cases 
widely distributed throughout the body. It is found in great numbers 
on the surface of the affected mucous membranes and in the false mem- 
brane itself, particularly in its superficial portion, but it does not invade 
deeply the subjacent structures. 

The frequency with which the diphtheria bacillus and other organ- 
isms are found in the blood and viscera in severe cases is shown in a 
series of 209 autopsies studied by Councilman, Mallory, and Pearce, of 
Boston, in 1901. The following table shows the percentage of cases in 
which the different bacteria were found by culture: 





Heart's blood. 


Liver. 


Spleen. 


Kidneys. 


Diphtheria bacillus 

Streptococcus 


per cent. 
20 
2.5 " 
1.5 u 


20 per cent. 
30 

4 

2.5 " 


12 per cent. 
27 

3 

1.5 " 


1!) per cent, 
28 


Staphylococcus aureus. . . . 
Pneumococcus 


s 
5 







In this series, 153 were cases of pure diphtheria ; 56 were complicated 
by measles or scarlet fever or both. The streptococcus was much oftener 



1024 THE SPECIFIC INFECTIOUS DISEASES 

found in the viscera in the complicated cases; otherwise there was little 
difference in the two groups of cases. 

The Diphtheria Toxins. — The wide-spread effects seen in diphtheria 
are due to the action of certain substances called toxins which the diph- 
theria bacillus produces during its growth on mucous membranes. They 
are very diffusible, readily entering the lymphatic circulation and the 
blood, and through these channels may affect the entire body. In 
susceptible animals there may be produced by the injection of these 
toxins all the characteristic lesions of diphtheria except the membrane, 
as well as the essential symptoms of the disease, even including paralysis. 
For the production of the membrane living bacilli are required. 

Catarrhal Diphtheria. — The routine practice of making cultures from 
diseased throats has established the fact that catarrhal inflammation may 
often be the only result of diphtheritic infection. Although to the naked 
eye there were only the ordinary changes of a simple inflammation, Oertel 
found the characteristic degenerative changes in the epithelial cells, vary- 
ing in degree with the severity of the process. 

The Diphtheritic Membrane. — The membrane in diphtheria is most 
frequently seen upon the mucous membrane of the tonsils, soft palate, 
uvula, pharynx, nose, larynx, trachea, and bronchi ; less frequently upon 
the mouth, lips, esophagus, conjunctivae, middle ear, stomach, and genital 
organs. It may also affect fresh wounds, notably a tracheotomy wound, 
or any abraded cutaneous surface. The gross appear auce of the mem- 
brane varies greatly. It is most frequently yellowish-white or gray, 
but it may be pearly-white, green, and sometimes almost black. It is 
composed of fibrin, cells, granular matter, and bacteria. Its consistency 
varies with the relative proportions of the different elements. When 
made up chiefly of fibrin it is firm and retains its form, often being 
discharged as a complete cast of the nose, larynx, or trachea. When the 
amount of fibrin is small the membrane is soft, friable, and sometimes 
granular. It is more closely adherent upon the mucous membranes cov- 
ered with squamous epithelium, as in the pharynx and upper air passages, 
than upon those covered with columnar and ciliated epithelium, as in the 
lower air passages. 

The microscopical examination shows the fibrin to be sometimes 
granular, but usually in the form of a network, inclosing in its meshes 
small round cells and epithelial cells in various stages of degeneration. 
On the surface and in the superficial layer there is usually found quite a 
variety of bacteria including diphtheria bacilli. Beneath this is a cellu- 
lar layer containing little or no fibrin, in which also the diphtheria 
bacilli are usually found. In the deepest parts of the false membrane 
and in the mucous membrane itself the bacilli are few in number or 
absent. 



DIPHTHERIA 1025 

Changes which are similar in all the affected mucous membranes, are 
found in the epithelial cells which undergo marked degeneration with 
fragmentation of their nuclei; the mucosa is infiltrated with leucocytes. 
The infiltration with small round cells is variable in degree in the differ- 
ent mucous membranes; in some it extends deeply into the submucous 
and even the muscular layers, while in others it is very superficial. 
Marked evidences of degeneration are seen also in the cells infiltrating 
the deeper layers. In places the epithelium is detached, in others the 
line between the false membrane and the granular mucous membrane 
is scarcely distinguishable. 

The Seat and the Distribution of the Membrane. — This varies some- 
what with the age of the patient, the season, and the peculiarity of the 
epidemic. 

Our own records show that the larynx is involved in about twenty-five 
per cent of the cases in children under three years. In general the state- 
ment may be made that the younger the child the greater the liability of 
the disease to attack the larynx. The larynx and lower air passages are 
rather more frequently attacked in winter than in summer. 

The tonsils are the most frequent and usually the earliest seat of the 
diphtheritic membrane; it may form here a tough, leathery patch, par- 
tially or completely covering and very adherent to them; or the disease 
may affect only the tonsillar crypts, so that the gross lesion may resem- 
ble that of ordinary follicular tonsillitis. There is in most cases only 
moderate swelling, but it may be so great that the tonsils are in contact. 
The surrounding cellular tissue is infiltrated with inflammatory products. 

The membrane covering the pharynx and uvula is also usually very 
adherent. The uvula is swollen and edematous. Membrane may be seen 
only upon the fauces and uvula, or the posterior and lateral pharyngeal 
walls may be covered down to the level of the cricoid cartilage, but gen- 
erally not below this point. If the posterior pharyngeal wall is covered, 
the membrane is apt to extend into the rhinopharynx, and even the pos- 
terior nares. 

The nose may be involved secondarily to the rhinopharynx, or the 
infection may be through the anterior nares ; if the latter, it is not infre- 
quently the only part involved. The membrane in the pure nasal cases 
is usually thick and tough and often separates en masse. 

The observations of Councilman, Mallory, and Pearce have shown 
that it is very common for the accessory sinuses of the nose, especially 
the antrum of Highmore, to be involved in fatal cases. It seems high Im- 
probable that infection of these parts explains the remarkable persistence 
o> diphtheria bacilli in the nose which is occasionally seen. 

The epiglottis is swollen to three or four times its normal thickness 
and the aryteno-epiglottic folds are edematous. The anterior surface 



1026 THE SPECIFIC INFECTIOUS DISEASES 

of the epiglottis is rarely covered by membrane; but its lateral borders 
and posterior surface, and the aryteno-epiglottic folds are involved in 
most of the severe pharyngeal cases. 

The lesions of the larynx, trachea, and bronchi are similar to the 
above, although much more superficial. The interior of the larynx may 
be completely covered, the membrane coating the true and false vocal 
cords and lining the ventricles of the larynx. The membrane in the 
larynx is not usually very adherent, and it frequently separates and is 
coughed up in large pieces or even as a cast. That covering the epiglot- 
tis and the aryteno-epiglottic folds is very adherent, like that, in the 
pharynx. 

In a considerable number of cases the membrane stops abruptly at 
the lower border of the larynx. In the trachea it is generally loosely 
attached, and often it is found at autopsy entirely separated from the 
mucous membrane. It is almost invariably associated with membrane in 
the larynx. As a rule, the bronchi of both sides are affected, and to the 
same degree. 

The extent of the membrane varies greatly in different cases. It 
may stop at the bifurcation of the trachea or at the bifurcation of the 
primary bronchi ; but if it goes beyond this point it is likely to extend 
to the minutest subdivisions. Exceptionally a very tough fibrinous mem- 
brane forms in the trachea and bronchi, of sufficient thickness and con- 
sistency to be expelled as a cast, reproducing almost the entire bronchial 
tree. 

The buccal cavity is very seldom covered by the membrane; but in 
the worst cases of pharyngeal disease it may line the cheeks, cover the 
lips, gums, and more or less of the hard palate, but rarely the tongue. 
It usually occurs in patches rather than as a continuous membrane. In 
one case we saw the membrane on the lower lip, extending on to the face, 
though the buccal cavity was free. It is not common for the diphtheritic 
membrane to spread down the digestive tract. In 127 autopsies studied 
by Councilman, Mallory, and Pearce, in which the extent of the mem- 
brane was carefully noted, it was found twelve times in the esophagus, 
five times in the stomach, and once in the duodenum. The accompany- 
ing changes consist in infiltration, hemorrhage, and cell degeneration. 
In the intestines there is often found a hyperplasia of the lymphoid ele- 
ments — solitary follicles and Peyer's patches — with changes similar to 
those in the lymph nodes elsewhere in the body, but nothing else that is 
characteristic. 

The writers just referred to found otitis, usually double, in sixty 
per cent of 144 autopsies ; although in less than one-third of the number 
was the complication recognized during life. Mastoid disease is infre- 
quent. Otitis is usually the result of direct extension from the pharynx. 



DIPHTHERIA 1027 

It may be due to the diphtheria bacillus, to the streptococcus, or to both 
combined. Conjunctival diphtheria is rare and probably due to acci- 
dental infection rather than to extension through the lachrymal duct. 
Before the advent of antitoxin, it almost invariably resulted in destruc- 
tion of the eye; but many cases successfully treated have been reported. 
Diphtheria may attack any mucocutaneous surface, especially the anus, 
prepuce, or female genitals; any abraded cutaneous surface, or recent 
wound, most frequently the tracheotomy wound of the neck. The diph- 
theria bacilli have in rare instances been found in pure culture in super- 
ficial abscesses. 

Visceral Lesions. — The visceral lesions of diphtheria are due partly 
to the action of the diphtheria toxins and partly to the invasion of the 
body with other organisms, especially the streptococcus. It is to experi- 
mental diphtheria that we owe our most accurate knowledge of the for- 
mer changes, for in human diphtheria the large proportion of all the 
fatal cases show infection with other organisms. 

The visceral lesions of diphtheria consist in wide-spread areas of cell 
degeneration similar to those which have already been described as occur- 
ring in the epithelial cells of the affected mucous membranes, together 
with hemorrhages due to changes in the blood-vessels and possibly in 
the blood itself. 

The lymph nodes of the cervical region are the most constantly and 
the most seriously affected. Similar but less marked changes are seen 
in the tracheobronchial and the mesenteric groups, and in the lymph 
nodules of the mucous membrane of the stomach and intestine. There 
are degenerative changes in the cells of the nodes most affected, with 
marked infiltration with leucocytes and frequently small hemorrhages. 
The cellular tissue in the neighborhood of the cervical nodes is often 
extensively infiltrated with cells. The process in the lymph nodes usu- 
ally terminates in resolution, rarely in suppuration. 

The spleen is swollen, sometimes very much so, and deeply congested. 
Hemorrhages are often seen beneath the capsule ; the spleen pulp is soft, 
the follicles are large, and cell degeneration is quite constantly observed 
similar to that which takes place in the lymph nodes. 

There are frequently small hemorrhages beneath the capsule of the 
liver, and sometimes these are seen throughout the organ. There are 
found scattered through the liver, areas of necrotic hepatic cells; sonic 
of these areas are infiltrated with leucocytes. 

The kidneys are involved in almost all fatal cases except when death 
occurs early from laryngeal stenosis, also in nearly every severe case 
which terminates in recovery. Acute degeneration of the epithelium 
of the tubes and the tufts is seen in less severe cases and those of shorter 
duration, and is the direct result of the action of the toxins. In the 



1028 THE SPECIFIC INFECTIOUS DISEASES 

more severe and protracted cases there is acute diffuse nephritis of vari- 
able type and intensity. 

In children dying suddenly in the early stage of the disease, cardiac 
thrombi are occasionally fonnd. They may form rapidly only a short 
time before death, or slowly during several days when the circulation 
is very feeble. Portions of these thrombi may be carried into the pul- 
monary or systemic circulation, causing embolism in any of the arteries 
of the extremities, the lungs, or other viscera. Even in the early fatal 
cases the heart muscle may be seriously affected ; in the later ones this 
is almost constant. The changes consist in a toxic myocarditis, the left 
ventricle being most involved. ( See Myocarditis. ) 

Degeneration of the arteries, especially of the endothelial layer, is 
occasionally seen, and there may be infiltration of the adventitia. 

Lesions of the brain are rare; both hemorrhage and embolism may 
be met with. In the spinal cord and membranes multiple hemorrhages 
occasionally occur. The chief lesion, however, consists in degenerative 
changes which are found to some degree in nearly all the more severe 
cases which have been examined. These affect the ganglion cells of the 
anterior horns, the anterior and posterior nerve-roots, and sometimes the 
pyramidal tracts and columns of Goll. Some writers are of the opinion 
that the cord lesions are primary and the degeneration of the spinal 
nerves secondary. However, the general opinion prevails that certainly 
the less severe cases of diphtheritic paralysis are due to peripheral rather 
than to central lesions. Degenerative changes have been found also in the 
pneumogastric, spinal accessory, hypoglossal, motor-oculi, and in the 
cardiac nerves. These nerve degenerations produced by the diphtheria 
toxin constitute one of the most striking lesions of diphtheria. (See 
Multiple Neuritis.) 

In infants and young children bronchopneumonia is found at au- 
topsy in fully three-fourths of the cases. It is well-nigh constant in cases 
of diphtheritic bronchitis of the finer tubes, and is usually present where 
the membrane has extended to the bifurcation of the trachea. The largest 
factor in the production of pneumonia is the aspiration of diphtheria 
bacilli and streptococci from the upper air passages. 

With laryngeal stenosis, some emphysema is invariably present, and 
usually it is of the vesicular variety. Eupture of some of the larger 
blebs may lead to the escape of air into the cellular tissue of the medi- 
astinum or of the neck, which may result in the production of a general 
emphysema of the subcutaneous cellular tissue. 

Blood. — There is found in all severe cases of diphtheria a reduction in 
the number of red cells to the extent of 500,000 to 2,000,000. There is a 
nearly proportionate reduction in the hemoglobin, this amounting to 
from 10 to 30 per cent. While the hemoglobin falls coincidently with 



DIPHTHERIA 1029 

the number of ed cells, it is regained much more slowly. Leucoey- 
tosis is genera^ ./ present, and usually proportionate to the severity of, 
the attack, but is occasionally wanting in the most severe as well as in 
some of the very mildest cases. The increase in the leucocytes is in the 
polymorphonuclear forms. Engel has noted the frequent presence of 
myelocytes, especially in fatal cases, the proportion of these in some in- 
stances reaching sixteen per cent of the white cells. 

Symptoms. — The clinical picture of diphtheria is one which presents 
wide variations, depending upon the principal location of the disease, its 
severity, and its complications. For practical purposes the following 
seems the simplest grouping that can be made: 

1. The mild cases, in which there is either no membrane, or the 
amount of membrane is small and limited to the tonsils or to the nose, 
with few or none of the constitutional symptoms which follow absorp- 
tion of the diphtheria poison. These cases partake essentially of the 
character of a local disease. 

2. The severe cases in which there are marked evidences of constitu- 
tional poisoning from the diphtheria toxin. This form is usually accom- 
panied by an extensive formation of membrane in the pharynx and 
sometimes in the nose. 

3. The laryngeal cases in which the larynx may be primarily or 
alone affected or in which it is involved secondarily to the severe pharyn- 
geal form. 

4. The malignant cases. In these cases the symptoms of inflam- 
mation are especially prominent, not only in the pharynx but sometimes 
in the lymph nodes and cellular tissue of the neck, which may be fol- 
lowed by suppuration or sloughing. This form is frequently complicated 
by bronchopneumonia even without laryngeal disease, and sometimes by 
severe nephritis. 

Cases ivithout Membrane. — During an epidemic of diphtheria in a 
family or an institution, cases are frequently seen which present the 
clinical evidences of only a catarrhal inflammation of the nose or pharynx, 
and yet cultures show the presence of the diphtheria bacillus. Such cases 
may be examples of simple catarrhal inflammation with the accidental 
presence of the diphtheria bacillus; or the inflammation may be caused 
by infection with the diphtheria bacillus, but not of sufficient intensity 
to lead to the production of a membrane. The latter is the view of 
pathologists, and the one to which clinicians must, if seems, inevitably 
come. 

Catarrhal diphtheria may be either pharyngeal or nasal. Tn the 
pharyngeal cases there are present the usual appearances belonging to 
a catarrhal inflammation of moderate severity, often accompanied by 
swelling and tenderness of the cervical lymph glands. 



1030 THE SPECIFIC INFECTIOUS DISEASES 

The nasal cases, in our experience, have been mosi frequent in in- 
fants or very young children. Constitutional symptoms may be wanting 
or so slight as to be overlooked. The only striking thing is a persistent 
nasal discharge which may be serous and frothy, purulent or bloody. It 
is usually copious, often excoriating the upper lip and sometimes con- 
tinuing for three or four weeks before any other symptoms are observed. 
We have several times known it to be mistaken for a syphilitic coryza. 
Such cases can be recognized with certainty only by cultures. Clinical 
evidence of their true character is sometimes afforded by the appearance 
of visible membrane in the nose or pharynx, by the development of croup, 
or by the fact that they cause diphtheria in other children. The bacilli 
are non-virulent in quite a large proportion of these cases, but in others 
they are of extreme virulence. 

Catarrhal diphtheria is not in itself serious, but it may be followed, 
particularly in young children, by laryngeal diphtheria, or pharyngeal 
diphtheria may develop in its usual form. 

Cases with a Small Amount of Membrane. — Tonsillar Diphtheria. — ■ 
The exudation is usually limited to the tonsils and may partake of the 
character of either follicular or croupous tonsillitis ; sometimes there is a 
slight extension to the faucial pillars or to the pharynx. These cases 
are quite common, and are more frequent in older children and adults 
than in infants and young children. 

The onset is accompanied by a little soreness of the throat ; the initial 
temperature is from 101° to 103° F. ; but the symptoms are often not 
severe enough to keep the patient in bed. If seen early, the throat shows 
slight redness, followed by a gray film, and later by a gray or white 
deposit upon the tonsils. This may start as a small patch which enlarges, 
or as small, isolated spots which coalesce or remain separate. The mem- 
brane is quite adherent, and can not easily be removed with a swab; 
usually it is sharply defined. In many cases the patch is not larger than 
the finger nail. The inflammatory changes in the pharynx are slight ; a 
faint red areola is present at the border of the patch. The lymph glands 
behind the jaw may be slightly swollen. There is no nasal discharge and 
very little increase in the saliva or mucus from the pharynx. Some con- 
stitutional symptoms are present, but they are not severe. The tempera- 
ture commonly continues above the normal while the membrane lasts, its 
usual range being from 100° to 102° F. The membrane remains from 
three to seven days — a shorter time if antitoxin is used. It is very often 
a matter of surprise that so small an exudate is so persistent. The urine 
is generally normal. The parents are loath to believe that strict quar- 
antine is necessary in so mild an illness ; and when the membrane is only 
upon the tonsils, even after the disease has run its course, the physician 
may be led to doubt the diagnosis of diphtheria. 



DIPHTHERIA 1031 

In many cases one with experience can usually make an accurate diag- 
nosis from the clinical symptoms alone; but there are many others in 
which the diagnosis from ordinary tonsillitis is impossible, except by cul- 
tures. When diphtheria bacilli are found in these mild cases the question 
often arises whether they may not be the non-virulent form. Park tested 
forty such cases, and found the bacilli to be virulent in thirty-five and 
non-virulent in five. In twenty of the forty cases the clinical diagnosis 
was follicular tonsillitis. 

Severe Cases. — The clinical picture of diphtheria is so modified by 
the use of antitoxin that those who see it given regularly and early can 
have but little conception of the horrors of this disease when not thus 
influenced. The onset in severe cases may be gradual, even insidious. 
There is then a slight indisposition for a day or two, and perhaps some 
soreness of the throat ; the temperature may be but little elevated, some- 
times less than 100° F. The symptoms may steadily increase in in- 
tensity for four or five days, until the maximum is reached. At other 
times the disease begins abruptly with vomiting, headache, chilly sensa- 
tions, and a temperature of 103° or 104° F. Occasionally, the first thing 
to attract attention is the swelling of the cervical lymph nodes, which 
may be so great that mumps is suspected. The abrupt onset is more often 
seen in young children than in those who are older. 

The membrane upon the tonsils resembles that of the mild form pre- 
viously described, but, instead of remaining limited to them, it gradually 
spreads to the fauces, the lateral wall of the pharynx, the uvula, the 
rhinopharynx, and the posterior nares. In some cases it may cover all 
the parts mentioned in twenty-four hours from its first appearance; in 
others this may require several days. When the nose is first affected 
there is an abundant discharge of serum and mucus, occasionally tinged 
with blood, which may continue some days before any membrane is vis- 
ible. 

When a severe case is fully developed there is a very abundant dis- 
charge of mucus from the mouth and nose. The tonsils, the entire fan- 
cial ring, and the pharynx are covered with membrane which is at firsl 
gray and gradually becomes darker, often being of a dirty olive-green 
color. There is obstruction to nasal respiration from the swelling of the 
palate, the tonsils, and the tissues of the rhinopharynx; the mouth is 
half open, the breathing noisy, the tongue dry, and the lips are fissured 
and bleed readily. Occasionally large nasal hemorrhages occur which 
may necessitate plugging the nares. Both nostrils are generally blocked 
by the swelling and the false membrane; the discharge excoriates the 
upper lip, and frequently has a fetid odor. During the second week 
there may be regurgitation of fluids through the nose, owing to paralysis 
of the palate. The lymph glands at the angle of the jaw swell rapidly ; 



1032 THE SPECIFIC INFECTIOUS DISEASES 

in severe cases they are very prominent, and there may also be extensive 
infiltration of the cellnlar tissue about them. 

The constitutional symptoms usually increase steadily with the ex- 
tension of the membrane. In the most severe cases the system is over- 
whelmed with the poison, and all the evidences of intense toxemia are 
present by the third day of the disease. This is shown by great muscular 
weakness and prostration, by a feeble, rapid pulse, and a mental state 
of complete apathy or stupor, sometimes alternating with great restless- 
ness* The pulse becomes rapid, weak, and compressible, sometimes irreg- 
ular ; the heart sounds are faint and there is a great and steadily increas- 
ing anemia. The course of the temperature is irregular, and may bear no 
constant relation to the severity of the other symptoms. Its usual range 
is from 101° to 103° F., but in some of the worst cases it may never go 
above 101° F. It fluctuates irregularly with the development of com- 
plications, and sometimes without apparent cause. By the second or 
third day the urine regularly shows the presence of albumin, and by the 
end of the first week the quantity is often large. Granular and hyaline 
casts, and occasionally blood in small quantities, are also found. The 
amount of urine secreted is not noticeably diminished, and dropsy is 
rare. Nervous symptoms are seen in all the very severe cases. There 
may be dulness and apathy, but more frequently, owing to the discomfort 
arising from local symptoms, there is extreme restlessness and excitement, 
sometimes followed by delirium. 

At any time during the first week, but not often after that time, 
symptoms may arise indicating that the disease has extended to the 
larynx. The first signs of laryngeal invasion usually appear from the 
second to the fifth day of the disease. These are at first hoarseness, a 
croupy cough, and slight dyspnea. In the severe cases these symptoms 
steadily increase until all the signs of laryngeal stenosis are present. 

The local process in the pharynx seems to be a self -limited one, even 
when no antitoxin is used. It usually reaches its height by the fifth or 
sixth day, and after that the appearances do not change materially for 
two or three days. From the seventh to the tenth day, in favorable 
cases, the diphtheritic membrane begins to loosen and separate from its 
attachment. It hangs loosely from the palate or uvula, and can often be 
pulled away in large masses. The detachment is frequently rapid, and 
in two or three days from the time when the first improvement is seen, 
the tonsils and pharynx may be almost free from membrane. The mu- 
cous surface left behind is of a bright-red color and bleeds easily. The 
separation of the membrane in the nose and rhinopharynx takes place 
more slowly. From the former it may disintegrate gradually or come 
away en masse. With the disappearance of the membrane the local symp- 
toms abate rapidly — the discharge ceases, the swelling of the lymph 



DIPHTHERIA 1033 

glands subsides, deglutition becomes easy and natural, and nasal breath- 
ing is re-established. When antitoxin is given the local process passes 
through similar stages, but much more rapidly. 

Simultaneously with these changes in the throat the constitutional 
symptoms improve, but much more slowly. Convalescence is often pro- 
tracted. The anemia and muscular weakness, and most of all the feeble 
heart action may persist for weeks. Symptoms due to myocarditis may 
appear in the second or third week or even later. (See Myocarditis.) 

Instead of the usual course just described, the diphtheritic mem- 
brane may persist for two or three weeks. In rare cases relapses occur, 
the membrane forming again after it has entirely or partially disappeared. 

The early course of the disease in the fatal cases often does not dif- 
fer from that of the severe cases which end in recovery, except in the 
malignant form, which kills in twenty-four or forty-eight hours, and 
which is rare. In very young children death is most frequently due 
to bronchopneumonia, usually accompanying diphtheria of the larynx 
and bronchi. It may also be due to progressive asthenia, the result of 
diphtheritic toxemia, or to heart failure. 

Laryngeal Diphtheria. — In cases of primary laryngeal diphtheria 
there are wanting most of the characteristic clinical features which dis- 
tinguish diphtheria of the pharynx. There are two reasons for this: 
one is the relatively rapid course of the disease, often producing death 
from local causes before the constitutional symptoms resulting from the 
absorption of the toxin have developed ; the second reason is, that absorp- 
tion of the poison by the laryngeal mucous membrane is very feeble as 
compared with that which takes place from the pharynx. Hence it 
follows that glandular enlargements, albuminuria and asthenic symp- 
toms are generally wanting; also, that in the cases which come to autopsy 
early, the parenchymatous degenerations of the heart, kidney, and other 
organs are seldom found, but instead only such lesions as are connected 
with the laryngeal disease. The feeble contagion is due to the fact that 
the course is much shorter, and that the discharge from the nose and 
mouth is slight, or absent altogether. 

In its onset, diphtheria of the larynx is indistinguishable from 
catarrhal inflammation. It is usually somewhat less abrupt, and ap- 
parently not quite so severe for the first twelve hours or even for a longer 
time. There are present the same hoarse cough and yoice, with slight 
stridor, gradually increasing. The constitutional symptoms arc usually 
not quite so marked, the temperature ranging from &9° to 101° F. The 
pulse is accelerated, but not weak or intermittent. It is the progress of 
the disease which indicates its character, usually during the firsl twenty- 
four hours. A child beginning in the morning with such symptoms as 
have been described, may by evening show a decided change for the 



1034 THE SPECIFIC INFECTIOUS DISEASES 

worse, or the symptoms may increase with great rapidity during the 
night. At first the voice is hoarse; later it is entirely lost. Dyspnea 
in the beginning is scarcely noticeable, but steadily increases hour by 
hour. Sometimes, from the first sign of hoarseness to such extreme 
dyspnea as to necessitate intubation may be but a few hours. During 
the second twenty-four hours all the symptoms are usually well developed. 
The respiration is often somewhat accelerated, but it may be slower 
than normal. The face is pale and anxious. The alae nasi dilate with 
each inspiration. The loud, "sawing," stridulous breathing is present, 
indicating obstruction both to inspiration and expiration. As the dys- 
pnea increases, all the accessory muscles of respiration are brought 
into action. There is now with every inspiration deep recession of the 
suprasternal fossa, the supraclavicular regions, and the epigastrium. The 
child tosses uneasily from side to side in his crib, at times struggling 
violently to get more air into the lungs. The pulse grows rapid and 
weaker. There is slight blueness of the finger nails and the lips; the 
face is usually pale; but later this too may be cyanotic. The skin is 
covered with clammy perspiration. On auscultating the chest, very rude 
respiratory sounds are heard, but no vesicular murmur. As the symp- 
toms increase in severity the temperature usually rises gradually, in some 
very severe cases at the rate of a degree an hour, until shortly before 
death it reaches 104° or even 106° F. Late in the disease the intellect 
becomes dull, the violent struggles for air cease, and the child passes into 
a condition of semi-stupor which gradually deepens until death occurs, 
which may be preceded by convulsions. 

Such is the usual course of the disease when unrelieved by treatment. 
Its progress is most rapid in infants, in whom death usually takes place 
in from thirty-six to forty-eight hours from the first symptoms. In older 
children the course is rather slower, and the attack may last from two- 
days to a week, death occurring more frequently from bronchial croup or 
pneumonia. They are indicated by continued high temperature, rapid 
respiration, cyanosis, and increased prostration. 

The course of the disease is not always so regular. Occasionally for a 
week or more the symptoms are precisely like those of catarrhal laryngitis 
of moderate severity — hoarseness, laryngeal cough, little or no fever, and 
slight or occasional dyspnea. Then there may be the sudden develop- 
ment of very severe symptoms, and death in a few hours. Great im- 
provement may follow the dislodgement of the membrane by vomiting or 
coughing, although in most cases it forms again. 

The issue of every case of diphtheritic laryngitis is doubtful. The 
prognosis is worse in infants and very young children than in those over 
three years of age. Before the days of antitoxin the mortality of cases 
not operated upon was from eighty to ninety per cent. Even with mod- 



DIPHTHERIA 1035 

em methods of treatment the outlook in infants under a year is bad; 
fully forty per cent die. 

It may be difficult in a given case to decide whether the dyspnea is 
due to laryngeal inflammation, and whether this inflammation is catar- 
rhal or diphtheritic. The dyspnea of retropharyngeal abscess, of for- 
eign bodies in the larynx or trachea, or of bronchopneumonia, may be 
mistaken for that due to laryngitis. But in none of these conditions 
should there be any doubt if a careful examination is made and a history 
obtained. Eetropharyngeal abscess may be recognized by digital ex- 
amination of the pharynx ; bronchopneumonia by the signs in the lungs, 
the difference in the character of the dyspnea, and especially by the 
absence of the noisy stridor; in the case of foreign bodies, whether they 
enter through the mouth or consist of ulcerating caesous glands which 
have ruptured into the trachea, the dyspnea comes suddenly, and is not 
accompanied by fever. The main points by which catarrhal laryngitis 
is distinguished from the diphtheritic form have been considered under 
the former disease. In brief, diphtheritic inflammation may be assumed 
if there is severe, constant, and increasing dyspnea with aphonia. 

Malignant Diphtheria. — The symptoms are usually severe from the 
outset. The exudation in these cases may be of a yellow, dirty-gray, 
or olive color, sometimes being almost black from the presence of blood. 
The membrane is usually extensive, covering the entire pharynx, often 
extending to the nose and the middle ear, and occasionally spreading to 
the buccal cavity. There is great swelling of the tonsils and uvula, and 
it is often impossible to obtain a view of the pharynx. Sometimes the 
inflammation is of a necrotic character, and there may be extensive 
sloughing of the tonsils, the uvula, or the soft palate. The nasal dis- 
charge is generally abundant, and often offensive. There is marked 
swelling of the cervical lymph glands, and frequently extensive infiltra- 
tion of the cellular tissue of the neck, so that the head is thrown back 
to relieve the pressure upon the larynx and trachea. The swelling some- 
times forms a distinct collar, reaching from ear to ear and filling out 
the whole space beneath the jaw. The pressure upon the jugular vein- 
leads to congestion and swelling of the face and congestion of the brain. 

The temperature is usually high; it follows no regular course, but 
generally fluctuates widely from 102° to 100° F. In some cases, how- 
ever, it may never be above 101° F. In the form characterized by very 
high temperature there is sometimes round a genera] streptococcus or 
pneumococcus infection, usually the former. The pulse is weak, rapid. 
and compressible. The peripheral circulation is poor, the extremities are 
often cold, there is extreme muscular prostration, and both vomiting and 
diarrhea are frequent. There may be excitement, restlessness, and active 
delirium, or dulness, apathy, and stupor. Nephritis is very frequent and 



1036 THE SPECIFIC INFECTIOUS DISEASES 

is often severe ; the urine contains a large amount of albumin and casts of 
all varieties, but rarely blood. In a large proportion of the children 
under three years old bronchopneumonia develops. Severe symptoms con- 
tinue for from two days to a week; the patient may die from the sud- 
den invasion of the larynx, or there may be suppression of urine and 
uremic convulsions ; but more frequently the cause of death is circulatory 
failure or bronchopneumonia. Death usually occurs while the local 
disease is at its height. Occasionally it comes later from myocarditis 
after the signs of local improvement have begun. Evidences of myocar- 
ditis are present post mortem in nearly every case. 

Those who manage to escape the dangers of the acute period have 
still others to encounter. Among the latter may be mentioned, ex- 
tensive sloughing in the throat or of the cellular tissue of the neck, 
which may be followed by severe or even fatal hemorrhage, diffuse sup- 
puration of the same region, late nephritis, pneumonia, or pleurisy, and 
finally paralysis of the heart or respiration. 

Complications and Sequelae. — Most of the complications of diph- 
theria have already been mentioned either under the head of Lesions or 
Symptoms. It only remains to consider their clinical association. 
^ Otitis occurs particularly in the rhinopharyngeal cases, and is some- 

times due to the diphtheria bacillus alone, but more often to mixed in- 
fection. The type of inflammation is often a severe one, and it may be 
accompanied by necrotic changes in the drum membrane which resem- 
ble those of scarlet fever. 

Bronchopneumonia is the most frequent complication in young chil- 
dren. It occurs especially in laryngeal cases, and in those of a severe 
type whether the larynx is involved or not. Other pulmonary compli- 
cations are infrequent. Emphysema is a complication of laryngeal diph- 
theria; it is nearly always vesicular, rarely interstitial. It may become 
general, extending into the cellular tissue of the neck and afterward that 
of the entire body. 

Pericarditis, endocarditis, and meningitis are all rare and are seen 
chiefly in septic cases of the most severe type. . Myocarditis is much 
more frequent, and is present to a greater or less degree in nearly all 
severe cases. It usually causes no distinctive symptoms but can be 
detected by physical examination. Heart block has been described in the 
course of and following diphtheria, but is rarely permanent. It is to be 
referred to a lesion of the bundle of His. 

Thrombosis and embolism are among the less frequent complica- 
tions. If cerebral, they may cause hemiplegia, aphasia, and sometimes 
convulsions; if peripheral, they usually affect one of the lower extrem- 
ities,, where they may cause sudden pain, numbness, and coldness of the 
limb, followed by partial paralysis, edema, and sometimes even by gan- 



DIPHTHERIA 1037 

grene. Thrombosis of the pulmonary artery or of the heart may be a 
cause of sudden death. 

Hemorrhages are usually nasal, and while in most cases they are not 
serious, they may necessitate plugging of the posterior nares. Bleeding 
from any other mucous membrane may occur, but it is rare except from 
the mouth. Subcutaneous hemorrhages are infrequent, and are evi- 
dence of a very high degree of diphtheritic toxemia. They usually 
occur as small petechial spots, but are sometimes extensive. They may 
be seen upon almost any part of the body, most frequently upon the 
abdomen and lower extremities; but the most extensive extravasation 
we have ever seen was in the neck, reaching from the clavicle almost 
to the ear and covering nearly one lateral half of the neck. 

Albumin is present in the urine of almost every case of moderate 
severity, usually depending upon acute degeneration of the kidneys. 
Acute nephritis is most frequently seen in severe cases. It then usually 
develops at the height of the local disease, but may come during con- 
valescence. Chronic nephritis very infrequently follows diphtheria. 

Diarrhea is of frequent occurrence. There may be no intestinal lesion 
or ileocolitis may be present, which, however, seldom goes on to ulcera- 
tion. It is extremely rare that the membranous form of ileocolitis is 
seen, and then it is associated with the presence of other organisms than 
the diphtheria bacillus. 

Diphtheria is usually followed by a severe and often persistent ane- 
mia which may continue for weeks. Pneumonia, nephritis, and cardiac 
disease may first show themselves during convalescence, and so be ranked 
as sequelae. The most important sequel of diphtheria, however, is post- 
diphtheritic paralysis, already discussed in the chapter on Multiple Neu- 
ritis. 

Pneumogastric Paralysis. — Some cases of diphtheria, especially those 
which receive no antitoxin or when the antitoxin is administered late or 
in too small amount, present a group of symptoms which have been 
referred to degeneration of the pneumogastric nerves. The evidence, 
however, is by no means conclusive that this is the true explanation of 
the clinical picture, which is a familiar one. 

These symptoms may come on at any time in the course of the disease, 
but seldom earlier than the end of the second week. By this time the 
throat has usually cleared off entirely, and the patient is considered 
convalescent. The symptoms relate to the stomach, the heart, and the 
respiration. Usually the first thing to attract notice is that the patient 
refuses food and vomits occasionally, afterward persistently, without ap- 
parent cause. If the pulse is carefully observed it is found to be much 
slower than previously, being only 80 or 90 when it was formerly 120 or 
more. It is also weaker, compressible, and often somewhat irregular. 



1038 THE SPECIFIC INFECTIOUS DISEASES 

The face is pale or slightly cyanotic, and moderate dyspnea may be 
noticed. There are frequent attacks of severe abdominal pain which 
comes in paroxysms, and is usually referred to the epigastrium. These 
symptoms in most cases gradually increase in severity for two or three 
clays, but sometimes develop with such intensity that death occurs within 
twelve or twenty-four hours. The later symptoms are a continuance of 
the abdominal pain and vomiting; there is a feeling of great precordial 
oppression and distress accompanied by dyspnea; the respiration is shal- 
low and often rapid ; the face is either pale or cyanotic ; the extremities, 
cold; the pulse, slow, irregular, and intermittent, becoming rapid on 
the slightest exertion. The heart sounds are weak, the muscular quality 
is absent, and the rhythm much disturbed. There may be no murmurs. 
There is great restlessness, but the mind is entirely clear. Death usually 
results from heart failure, which may come quite suddenly, often from so. 
slight exertion as turning over in bed or attempting to take food. 

Not all the cases are so severe. In the milder forms there is some 
palpitation, an irregular pulse, slight dyspnea, and occasional syncopal 
attacks, but of no great severity. Such symptoms may come and go 
for several days and then disappear ; but more frequently they prove to 
be the beginning of the more serious form of the complication. The 
time of occurrence of these symptoms varies considerably. It may be 
as late as the third or fourth week. The late cases are generally asso- 
ciated with some other form of postdiphtheritic paralysis. 

Sudden heart failure may be seen late in diphtheria quite apart from 
the symptoms just described. It may occur with few or no premonitory 
symptoms; as when a child falls dead after walking across a room, or 
suddenly sitting up in bed, or from some other muscular effort, or pos- 
sibly as a consequence of passion or excitement. We knew of one little 
girl who was considered well enough to go coasting and who died sud- 
denly after the effort. 

The explanation of heart failure during or after diphtheria is there- 
fore not always the same. When it occurs at the height of the disease 
it is sometimes due to cardiac thrombosis, probably always associated 
with changes in the muscular walls. When it occurs late and follows 
some sudden muscular effort or excitement without premonitory symp- 
toms of any sort, it is probably the result of changes in the muscular 
walls — a true myocarditis. 

Diagnosis. — The diagnosis of diphtheria rests upon two kinds of 
evidence — clinical and bacteriological. In mild cases and in the early 
stage only bacteriological evidence can be relied upon. However, the 
clinical manifestations of the disease are important and should not be 
ignored. It is in most cases possible to say from clinical symptoms that a 
case is one of diphtheria; but it is never possible to say from symptoms 






DIPHTHERIA 1039 

alone that a case is not one of diphtheria. Cultures, therefore, should, 
if possible, be made in every case. They are necessary in the mild cases 
in order that a correct diagnosis may be made and proper quarantine 
regulations enforced. 

The mere presence of diphtheria bacilli in the throat does not prove 
that a person has diphtheria any more than the presence of the pneumo- 
coccus in his saliva proves that he has pneumonia ; but when diphtheria 
bacilli are associated with clinical evidences of inflammation of the 
throat or nose the diagnosis may be regarded as established. Again, the 
case may be one of diphtheria and the bacilli not found at the first 
examination, although found subsequently. In using antitoxin one must, 
in perhaps the majority of cases, be guided hy clinical symptoms alone, 
not waiting for the result of the bacteriological examination. It is there- 
fore important that both methods of diagnosis should be employed. 

1. The Clixical Diagnosis. — Xot much importance can be attached 
to the mode of onset; for diphtheria may begin in many different ways. 
The presence of a nasal discharge, especially if abundant, ichorous 
and tinged with blood, the early development of the symptoms of croup, 
and the rapid enlargement of the cervical lymph nodes, all point strongly 
to diphtheria. Later symptoms which are especially diagnostic are 
marked anemia, progressive asthenia, very feeble pulse which is some- 
times slow, sometimes rapid, sudden attacks of syncope, nasal regurgita- 
tion from paralysis of the soft palate, contagion, and, finally, the develop- 
ment of paralysis of the muscles of the throat, eye, or extremities, with 
paralysis of the heart or respiration. 

The membrane of diphtheria generally appears first upon the tonsils, 
usually as a gray film which gradually becomes more dense and white, 
and often has the look of being plastered on. The color of older mem- 
brane is gray, greenish-yellow, brown, sometimes black. Beginning as 
a small patch, it soon covers the tonsils. It frequently affects one tonsil 
twenty-four or thirty-six hours before the other, and occasionally it is 
confined to one side. In exceptional cases it begins in the crypts of the 
tonsil and appears as isolated dots, which may coalesce to form a con- 
tinuous patch like that already described, or it may remain isolated like 
the exudate of an ordinary follicular tonsillitis. More important is 
the fact that the membrane spreads from the original seat, and also the 
manner of its spreading. If it extends beyond the tonsils to the walls 
of the pharynx, the faucial pillars, and the uvula, it is almost surely 
diphtheria. The same is ir\\(' of doubtful patches <>n the tonsils or fauces 
followed by symptoms of croup. The rapidity of the spreading varies 
much in the different cases, but the gradual extension, as shown by obser- 
vations made at intervals of six or eight hours, usually settles the diag- 
nosis in the primary cases. However, if the throat symptoms complicate 



1040 THE SPECIFIC INFECTIOUS DISEASES 

measles or scarlet fever the above rules do not apply. Most of the mem- 
branous inflammations of the throat seen in these diseases are not due to 
diphtheria. This is particularly true of those which occur at the height 
of the primary disease. Those which develop at a later period are often 
due to diphtheria. 

Primary membranous inflammation of the larynx may always be 
safely regarded as diphtheria; but if there is no visible membrane, the 
diagnosis is rendered positive only by a bacteriological examination. 
This may be true of many nasal cases where the only symptoms are a 
discharge of the character previously described. Such cases may con- 
tinue for weeks with no symptoms other than the discharge, especially 
in infants. 

It is seldom difficult to distinguish diphtheria from other diseases; 
but the exudation upon the pharynx or tonsils may be confounded 
with thrush or ulceromembranous angina. The appearance of the ton- 
sils on the second or third day after tonsillotomy has been performed, 
may easily be mistaken for diphtheria by one who is unfamiliar with the 
appearance of the postoperative wound. 

Diphtheria of the mouth may be mistaken for herpetic or ulcerative 
stomatitis ; but, as a rule, it is seen only in the worst cases of pharyngeal 
diphtheria. Diphtheria of the mouth alone is so rare that it may be 
ignored. 

It is sometimes difficult to distinguish cases of scarlet fever in which 
the throat symptoms are severe and appear early, from cases of primary 
diphtheria. In many of these cases the eruption appears late, and is 
not characteristic. Much importance is to be attached, as pointing 
toward scarlet fever, to a prevailing epidemic, a history of exposure, a 
sudden onset with severe symptoms, vomiting, prostration, very high 
temperature, and to a very active inflammation in the pharynx. In all 
cases with a sudden onset, in which from the throat symptoms one is 
inclined to make a diagnosis of diphtheria, the possibility of scarlet fever 
should not be forgotten, and one should never omit to examine the patient 
thoroughly for an eruption. 

2. The Bacteriological Diagnosis. — The Technic. — In many cases 
an immediate diagnosis may be reached by the examination of a cover- 
glass smear from the throat. This method, although often valuable, is 
not adapted for general use, as bacilli directly from the throat are much 
less typical than those from cultures, and the chances of contamination 
are much increased. Furthermore, the mouth often contains other bacilli 
which somewhat resemble the diphtheria bacillus. 

In taking a culture from the throat nothing but the membrane should 
•be touched and this should be rubbed firmly with a swab, which is then 
rubbed over the surface of the culture-medium. In laryngeal cases the 



DIPHTHERIA 1041 

culture should be taken from the posterior wall of the pharynx, and in 
nasal cases from the nostril. 

The Reliance to he Placed upon Bacteriological Diagnosis. — The diph- 
theria bacillus will almost invariably be found, if there is visible mem- 
brane in the pharynx, if no antiseptics have been applied shortly before 
using the swab, and if the culture has been made with sufficient care to 
avoid contamination. 

The diphtheria bacillus sometimes disappears early; hence cultures 
made while the membrane is loosening may be negative. If the mem- 
brane has disappeared, or if none has been present, it is not infrequently 
necessary to obtain material from the tonsillar crypts in order to dis- 
cover bacilli. It is therefore important in all cases to consider the dura- 
tion of the disease before drawing a conclusion from a negative culture. 
In cases of laryngeal disease without pharyngeal exudation, an early 
culture is negative in nearly half the cases ; although a little later bacilli 
may be coughed up and found in the pharynx in abundance. A single 
negative culture should never be taken as conclusive. 

For diagnostic purposes, all bacilli present in suspicious throats, hav- 
ing the morphological and cultural characteristics of diphtheria bacilli, 
are to be regarded as virulent. 

Non-virulent Bacilli Resembling the Diphtheria Bacillus. — There 
may be found in throats a form which corresponds in every other charac- 
teristic with the diphtheria bacillus, but which lacks virulence, as shown 
by animal tests. Also, another form, which, though in many particulars 
resembling the diphtheria bacillus, differs from it in being shorter, 
plumper, and more uniform in size, and in producing an alkali in broth 
cultures; to this the term pseudo-diphtheria bacillus has been given. It 
is more frequently seen than the form just described and like it is non- 
virulent. Both these forms are rare in throats where a suspicion of diph- 
theria exists. 

The Presence of Virulent Bacilli in the Throats of Healthy Persons. 
— That virulent bacilli may be harbored for an indefinite period in the 
throat or nose of a healthy person is proved by many observations. The 
New York Health Department made observations upon forty-eight chil- 
dren in fourteen families in which one or more cases of diphtheria had 
occurred, and where no attempt at isolation had been made. In one- 
half these cases bacilli were found, and animal tests showed them to be 
virulent in every one of six cases tested, alt hough four of the children 
did not develop diphtheria. Of the entire Dumber, forty per cent subse- 
quently developed diphtheria. Our own experience in two institutions 
where diphtheria has been endemic, fully confirms the observation that 
bacilli of all degrees of virulence are very frequently found in the noses 
or throats of exposed children, although a large proportion of them 



1042 THE SPECIFIC INFECTIOUS DISEASES 

never develop the disease. Outside of institutions and infected tene- 
ment houses, however, such a condition is much less common. Moss and 
Guthrie took cultures from 1,217 public school children in Baltimore. 
In 44 children diphtheria bacilli were found, but in only eight were they 
virulent. 

Prognosis. — Many possibilities exist, and even the mildest case must 
be regarded as serious and carefully watched, since one can never know 
when unfavorable symptoms may develop. 

The factors to be considered in the prognosis of any given case are : 
the age and previous condition of the patient; the extent of the mem- 
brane and the rapidity with which it is spreading; the degree of diph- 
theritic toxemia as shown by the condition of the pulse and the nervous 
symptoms; whether or not the membrane has invaded the larynx; and 
the presence or absence of complications, especially nephritis and bron- 
chopneumonia ; but of more importance than any or all these things is 
whether antitoxin is used and when it is administered. 

The following figures are from the Report of the Health Depart- 
ment of Chicago of cases treated for a series of years. 

Died. Mortality. 

Injected 1st day 355 1 . 27 per cent. 

2d day 1,018 17 1.67 " " 

3d day 1,509 57 3 . 77 " " 

" 4th day 720 82 11 .39 " 

later 469 119 25.37 " " 



Totals 4,071 276 6.77 " " 

In all these cases the diagnosis of diphtheria was confirmed by cul- 
tures. 

Diphtheria mortality is highest during the first two years of life, 
from its strong tendency to invade the larynx and lower air passages, 
and from the frequency with which bronchopneumonia occurs as a com- 
plication. Those whose experience with this disease does not antedate 
the introduction of antitoxin can scarcely appreciate the results previ- 
ously obtained. Of eighty-five consecutive cases under twenty-six months 
of age observed in the New York Infant Asylum, in a period extending 
over two years, the mortality was sixty-eight per cent ; in over two-thirds 
of the fatal cases the disease involved the larynx. In diphtheria hos- 
pitals, where most of the mild cases included in the above statistics would 
probably not have been admitted, the mortality in children under two 
years formerly varied from sixty to eighty per cent; in private practice 
it ranged for this age from thirty to sixty per cent. 

It can not be too often emphasized that the danger from diphtheria 
is not over when the throat has cleared. The most frequent causes of 
death after this time are bronchopneumonia and cardiac paralysis. 



DIPHTHERIA 1043 

Prophylaxis. — In no infectious disease, smallpox alone excepted, can 
so much be accomplished in the way of prevention as in diphtheria. 

Public funerals of children dying from diphtheria should invariably 
be prohibited. Schools should be closed whenever the disease is epi- 
demic. Children from families where diphtheria exists should not be 
allowed to attend school, nor mingle in any way with other children, 
for the reasons that they may, while healthy, be the carriers of the dis- 
ease; and, what is even more important, that they may be themselves 
suffering from diphtheria in an early stage or in a mild form. 

In every large city, hospitals for diphtheria patients should be estab- 
lished, not only for the poor, but with private rooms for cases develop- 
ing in hotels or other places where isolation is impossible. Every city 
should be provided with a steam disinfecting plant, where carpets, blan- 
kets, bedding, etc., can be sent from the sick-room for disinfection. 

Quarantine:- — Not only every undoubted case of diphtheria, but every 
suspected case, should be immediately isolated. Quarantine for the lat- 
ter should continue until the diagnosis is settled either by a bacterio- 
logical examination or by the course of the disease. Positive and sus- 
pected cases should not be isolated together. The quarantine in every 
instance must be complete. If possible, cultures should be taken from 
the throats of all exposed children. Those containing diphtheria bacilli 
should be quarantined like cases of diphtheria, for they may be equally 
dangerous; they should use gargles and sprays, and the nose and throat 
should be closely watched. 

Bacteriology has furnished some very definite data from which the 
necessary duration of the period of quarantine may be determined. In 
this the physician is to be guided by the time that the bacilli remain in 
the throat, for the patient is to be considered as dangerous while they 
persist. This point was investigated by the New York Health Depart- 
ment in 605 cases : In 304 of these the bacilli had disappeared by the 
third day after the membrane was gone; and in 301 they persisted for a 
longer time — in 176, for seven days; in 64, for twelve days; in 36, for 
fifteen days; in 12, for twenty-one days; in 4, for twenty-eight days; in 
4, for thirty-five days; and in 2, for sixty-three days. In many of the 
cases in which the bacilli persist for an unusual time they are found 
deep in the crypts of the tonsils. Others are cases of nasal diphtheria : 
in some of these doubtless the antrum has been invaded. While it is 
unquestionably true that in a certain number of cases these persistent 
bacilli are non-virulent, the opposite has been frequently shown. Of 
15 cases in which the virulence was tested, virulent bacilli were found 
in 9 at periods varying from eight to twenty-five days after the membrane 
was gone. 

Treatment of Suspected Cases. — During an epidemic of diphtheria. 



1044 THE SPECIFIC INFECTIOUS DISEASES 

especially in an institution, every child with sore throat or nasal dis- 
charge should be looked upon with suspicion, and isolated pending the 
result of a bacteriological examination, even though no membrane is 
present. If there are patches on the tonsils or any other visible mem- 
brane, the case should be treated as true diphtheria, in order that no time 
may be lost. If the bacteriological examination shows the disease not 
to be true diphtheria, the patient may be released from quarantine in 
two or three days, provided the throat symptoms disappear. It is, of 
course, important that the conditions laid down with reference to bac- 
teriological diagnosis shall have been fulfilled. Should symptoms con- 
tinue, however, a second culture should be taken. 

Immunization of Persons Exposed. — When a case of diphtheria oc- 
curs in a family or an institution, every child and all adults should have 
their immunity determined by the Schick test. This is based upon the 
irritating action of unneutralized diphtheria toxin upon tissues, when in- 
jected intracutaneously even in the minute amount. The test therefore 
determines the presence or absence of natural antitoxin, and indicates 
whether or not persons are susceptible to the disease. 1 

The New York Health Department supplies an outfit for making this 
test. 

Those persons with an immunity do not require antitoxin. Children 
who give a positive Schick reaction should be immunized. Adults who 
are not immune should be carefully observed. If they are to come in 
close contact with diphtheria patients they also should receive an immu- 
nizing dose of antitoxin. When it is impossible to apply the Schick test, 
children under five years of age should be immunized with antitoxin at 
once. With older children immunization may be postponed, provided 
only that they can be observed at least twice a day. If this can not be 
thoroughly done, all children under ten years of age should receive a 
prophylactic injection of antitoxin. Those older may be treated as adults 
are treated by close observation, but without antitoxin unless sore throat 
or other suspicious symptoms arise. 

'•The method of applying the Schick test is as follows: With a fine hypo- 
dermic needle and using a carefully graduated syringe 1/50 of a minimum lethal 
dose for the guinea-pig, of diphtheria toxin is injected intracutaneously in .1 or 
.2 c. c. of salt solution. 

If natural antitoxin is present no reaction occurs beyond that due to the small 
puncture. If no antitoxin is present a circumscribed area of redness, ^ cm. in 
diameter, appears in twenty-four to forty-eight hours. This persists for six to ten 
days and gradually disappears, leaving a brownish pigmented spot that scales 
superficially, and that may be appreciable for months. There are no constitu- 
tional symptoms and no pain. The test is sharp and accurate. Occasionally 
a pseudo-reaction may be seen. This appears earlier and disappears in 48 hours. 
The area is less sharply circumscribed and more indurated. 



DIPHTHERIA 1045 

The dose for immunization is from 500 to 1,000 units, the former 
being that required for an infant, and the latter for older children. 
There is no doubt that for a limited time — from two to three weeks — 
almost complete protection is conferred. 

Diphtheria so often complicates scarlet fever and measles, particularly 
in institutions and in hospitals for contagious diseases, that special 
consideration should be given to such patients. The Schick test should 
be made on all, and those patients with no natural immunity should 
be given antitoxin. If the test can' not be made, the only safe rule is to 
immunize every child admitted to a scarlet fever or measles hospital, and 
in institution epidemics of either of these diseases to immunize every 
child attacked. 

A nurse who is not immune to diphtheria should not work in infec- 
tious hospitals nor, ordinarily, care for diphtheria patients in private 
practice. If it is necessary for her to take care of a diphtheria patient 
she should receive 1,000 units of antitoxin. These general rules do not 
apply to physicians who are in less close contact with patients. They 
should take the same precautions as in scarlet fever. 

The injection of a mixture of toxin and antitoxin in which the toxin 
is not completely neutralized is often used with animals to cause a 
production of antitoxin. Theobald Smith suggested such a mixture for 
the immunization of children and von Behring put it to the practical 
test. Eecent observations by Park and Zingher have shown that this 
method not only increases greatly the amount of antitoxin present in 
the blood of immune persons, but causes the production of antitoxin in 
a large proportion of those who are susceptible to the disease. A com- 
bination of the mixture with a vaccine of killed diphtheria bacilli seems 
to be advantageous. The effect is not evident at once, but after several 
weeks an immunity can be demonstrated which has been proven to last 
for many months; how much longer it is as yet impossible to say. 
Forty out of fifty susceptible persons in Park and Zingher's series de- 
veloped an antitoxic immunity. It is evident that a means is thus offered 
of producing immunity in susceptible persons, which may be of great 
service, not only for the individual, but one which can be employed to 
prevent outbreaks of diphtheria in institutions in which children, remain 
for a length of time. The method is not, however, applicable for use 
during epidemics. 

Treatment. — General Measures. — The directions to be carried out in 
the sick-room have been outlined in the introductory pages on Infectious 
Diseases. It is important in every case of diphtheria that there should 
be plenty of fresh air in the room throughout the attack. Hospital 
patients should never have less than 1,000 cubic feet of ail space, and 
if possible 1,200 should be allowed. Even in mild attacks the patient 



10 46 THE SPECIFIC INFECTIOUS DISEASES 

should be kept in bed throughout the entire illness, and in severe attacks 
this should be continued for some time during convalescence. 

Nursing infants may be fed on breast-milk obtained by a breast- 
pump, but should not be put to the mother's breast. Those who are not 
nursed and older children should be fed very much as in other cases of 
severe illness. Milk is the main reliance; it should usually be diluted. 
The greatest difficulty in feeding is seen in the latter part of the disease, 
when the patients are septic and have a strong aversion to food, when 
vomiting is easily excited and when swallowing is difficult on account of 
the swelling and pain. It is then that gavage is most valuable. In 
older children the tube may be passed through the nose. 

Stimulants. — In most cases they are not needed until the third or 
fourth day, and in many they may not be required at all. The indica- 
tions for stimulants are marked prostration, a feeble pulse, and a weak 
first sound of the heart. Of alcohol, half an ounce of whisky or brandy 
in twenty-four hours is enough for a child four years old. This should 
be diluted with at least eight parts of water. In very severe cases two or 
three times as much may be given; but more than this, except for a 
short period, is seldom wise. More reliance is to be placed upon the 
other circulatory stimulants, especially caffein, camphor, and digitalis, 
which are given for the same indications as in other acute diseases. In 
cases of threatened cardiac paralysis occurring late in the disease or dur- 
ing convalescence, morphin should be used hypodermically. Full doses 
must be given and repeated every two to four hours, so that the child may 
be kept under its influence. 

Except for stimulation or the control of special symptoms such as 
diarrhea, all internal medication should be omitted; for there is yet 
wanting proof that drugs influence the course or the result of the 
disease. 

Local Treatment. — -Since the introduction of antitoxin local treat- 
ment has become a matter of secondary importance; and under condi- 
tions when it can be carried out only with great difficulty and the use of 
force it is often wise not to attempt it regularly. 

The purpose of local treatment, it is now generally agreed, should be 
cleanliness, and not the destruction of bacilli. Cleanliness of the nose, 
mouth, and pharynx is important, inasmuch as one of the chief dangers 
of the disease is the aspiration of bacteria contained in the abundant 
secretions of these parts, into the larynx and bronchi. Our aim should 
therefore be to keep the parts as clean as possible without too severely 
taxing the strength of the child. 

For cleansing the nose and pharynx only syringing can be depended 
upon, Nasal syringing is indicated when there is much nasal discharge, 
whether membrane is visible in the anterior nares or not. In septic 



DIPHTHERIA 1047 

cases with a profuse fetid discharge it may be necessary to syringe the 
nose, no matter how strongly the child resists. Whether it shall be 
done, will depend npon the condition of the patient's strength and his 
pulse. The purpose in syringing is not so much to clear the nose, from 
which absorption is slow and imperfect, as to flush the rhinopharynx, 
from which absorption is always very active. Only bland solutions 
should be employed, such as a saline solution, one per cent, or a boric- 
acid solution, one- to four-per-cent strength. For some cases, a piston 
syringe may be used; but for most a fountain syringe possesses man- 
ifest advantages, and it is more convenient for hospital purposes. Irri- 
gation of the pharynx is best done with the fountain syringe, and is 
of especial value where there is much swelling or abundant discharge. 
All solutions should be used as warm as can be borne, and in sufficient 
quantity to irrigate the parts thoroughly, a few such irrigations being 
much better than a great many partial ones. By a skilful nurse syringing 
can in most cases be done with comparatively little disturbance to the 
child. 

Slight nasal hemorrhages may necessitate less frequent syringing, 
and a free hemorrhage may require it to be discontinued. Astringent 
solutions of alum and epinephrin are often beneficial in such cases, but 
they must be used carefully. In children who are old enough gargles 
should be used. A solution of boric acid, or Dobell's or Seller's solution 
much diluted, may be employed. 

In cases with a moderate nasal discharge it is usually sufficient to 
syringe three or four times a day; but in severe septic cases, with very 
abundant discharge, syringing should be repeated as often as every two 
hours during the day and every four hours at night. 

External applications have no effect upon the disease, but are often 
useful to relieve pain and tension in the swollen lymph-glands. Poultices 
should not be employed. As a continuous application, only cold is to be 
advised, generally by means of an ice-bag well protected to prevent wet- 
ting the clothing. 

The treatment of cardiac and other forms of post-diphtheritic paral- 
ysis has been considered in the chapter on Multiple Neuritis. 

The Serum Treatment. — Antitoxin is produced by the cells of the 
body under the stimulus of the diphtheria toxin. It is intimately com- 
bined with the globulin of the blood, and is itself possibly a globulin. It 
directly neutralizes the toxin produced by tin: diphtheria, bacillus, and 
also has some effect upon the bacilli themselves, the nature of which is 
not understood. It induces a condition in the blood which inhibits the 
growth of the bacilli, and thus arrests the membranous inflammation 
which they excite. 

Properly prepared, it will keep without deterioration for from throe 



1048 THE SPECIFIC INFECTIOUS DISEASES 

to six months; but after one year it loses somewhat its antitoxic prop- 
erties. It should be kept in a cool, dark place, and after a bottle has 
been opened it should be used within a few days. Antitoxin is now 
prepared in a dry form, which is to be preferred only when it must be 
kept for a very long time. 

The strength of the serum is measured in antitoxin units, the unit 
being an arbitrary one, viz., the amount of antitoxin which will protect 
a guinea-pig weighing 250 to 300 grams against one hundred times the 
fatal dose of diphtheria toxin. Behring's serum first used contained but 
one unit in each c. c. At present there can be obtained sera containing 
1,000 antitoxin units or more in each c. c. This concentration is of 
immense advantage and has to a large degree done away with the un- 
pleasant symptoms. 

Method of Administration and Dosage. — The skin should be thor- 
oughly cleansed with alcohol; the needle should invariably be boiled and 
the whole syringe either boiled or rinsed with alcohol. The seat of injec- 
tion is not a matter of great importance; our own preference is for the 
cellular tissue of the abdomen or axilla or the muscles of the buttock. 
Absorption from the cellular tissue is slower than from the muscles. 
For very rapid effect, however, intravenous injections should be em- 
ployed. After the injection is made the puncture should be covered by 
adhesive plaster. 

The union of the toxin with the cells takes place rapidly. To prevent 
this the maximum required dose should be given early in a single injec- 
tion, rather than in divided doses. While the deleterious effect of the 
toxin bound to the cells can not be neutralized except to a slight extent, 
the blood can be supplied with sufficient antitoxin to neutralize new toxin 
as fast as it is produced. Convinced now of the essential harmlessness 
of the serum, the tendency everywhere has been to use larger and larger 
doses. For a child over two years old an initial dose for a severe attack, 
including all laryngeal cases, should not be less than 7,000 or 8,000 units 
administered intramuscularly or preferably intravenously. Children 
under two years should receive from 5,000 to 6,000 units. Cases of 
exceptional severity, in older children, should receive from 10,000 to 
15,000 units intravenously. Mild cases should receive from 3,000 to 
5,000 units, a repetition of the dose in any patient being usually unneces- 
sary. 

In cases receiving antitoxin late, even though the symptoms may 
not seem particularly severe, the dose should be increased in proportion 
to the length of the illness, and given intravenously. Only serum from 
a trustworthy manufacturer should ever be used. The most concentrated 
serum which can be obtained should be selected. 

All experience shows that the results are greatly modified by the 



DIPHTHERIA 1049 

time of its administration. The serum can not undo the serious damage 
already done to the cells of the body, and this at the time of injection 
may be so great that death will result. In very mild cases, with older 
children, one may wait for the result of a bacteriological examination, 
but never in a severe case and never in a young child. In the group of 
severe cases should be placed every one which at the first visit shows a 
pharyngeal exudate covering more than the tonsils, also all cases with 
symptoms of laryngeal invasion, and all with an exudate on the pharynx 
and a profuse nasal discharge. If in a doubtful case twelve hours' ob- 
servation shows that the membrane has spread from its original seat, no 
further delay is admissible. In human diphtheria marked benefit usually 
follows injections made as late as the third day; but after this time the 
value of the serum diminishes very rapidly, and although striking ex- 
amples of benefit are sometimes seen after later injections, they can not 
be depended upon. In very severe or in malignant cases so much harm 
may be done during the first twenty-four hours of the attack that the 
subsequent use of antitoxin is without avail. 

The effect upon the diphtheritic membrane is usually noticeable 
within twenty-four and often in twelve hours; it first stops spreading, 
and soon begins to soften and loosen. The swelling of the mucous mem- 
brane subsides and the local disease abates, very much as when the dis- 
ease runs its usual course. The striking thing after the use of antitoxin 
is the rapidity with which these changes take place, and the abrupt tran- 
sition from an advancing to a retrograde process. The subsidence of 
the inflammatory conditions in the larynx and trachea is quite as marked 
as in the pharynx. The symptoms of stenosis, even when severe, often 
diminish in a few hours, making operation unnecessary in a very large 
number of cases when previously it seemed inevitable. The membrane 
loosens rapidly in the larynx and trachea, sometimes necessitating the 
frequent removal of the intubation tube, when operation has been per- 
formed. Improvement is also shown by the cessation of the nasal dis- 
charge, the re-establishment of nasal respiration, and the diminution in 
the swelling of the glands of the neck. 

The effect upon the constitutional symptoms is not less striking. In 
favorable cases there is seen, often in twelve hours, a fall in tempera- 
ture and improvement in the pulse and in the nervous symptoms. 

The Limitations of Antitoxin. — It is important that these should 
always be kept in mind. The serum mus1 be given early, for if given 
late it can not undo the mischief already done by the diphtheria l<>\in. 
Cases of great severity have often passed the period when recovery was 
possible, before the antitoxin is given. This period may in some cases be 
four days, in others it may be less than twenty-four hours. The tissues 
most susceptible to the diphtheria toxin are probably those of the nervous 



10 50 THE SPECIFIC INFECTIOUS DISEASES 

system, the heart, and the kidneys; and the consequences of its action 
may be seen in the production of nephritis, in heart failure at the height 
of the disease, or in later paralysis of the heart, respiration, or the volun- 
tary muscles, in spite of the fact that antitoxin is given at a period early 
enough to avert death from local disease in the larynx or bronchi. 
Against the phlegmonous inflammation of the throat or the cellular 
tissue of the neck, bronchopneumonia, and nephritis, antitoxin is power- 
less; and just in proportion to the severity of these inflammations are 
negative results seen. 

Eruptions and Other Unpleasant Effects. — Some transient, local 
edema usually follows the injection and a slight rise of temperature is 
very frequently observed. In a few hours there may be seen a general 
erythema; this, however, is rare and usually of short duration. The 
most important eruptions are seen between the eighth and fourteenth 
days. They follow from five to ten per cent of the injections made, and 
appear to be quite independent of the amount of serum used. The exact 
cause is not known. The most common eruption is urticaria. This is 
often intense, very annoying, and may nearly cover the body. It may 
be accompanied by a slight rise of temperature ; it usually lasts for two 
or three days; but is rarely severe for more than twenty-four hours. 
Various forms of erythema are occasionally met with. In several in- 
stances we have seen hemorrhagic eruptions, generally in the neighbor- 
hood of the large joints, and always in children suffering from extreme 
malnutrition. In a few cases a moderate swelling of some of the joints 
lias been observed, and a transient albuminuria. One occasionally meets 
with patients who seem unusually susceptible to serum injections, and 
in whom even small immunizing doses cause headache, muscular pains, 
and general malaise, so that they feel quite wretched for several days. 
All of the above symptoms except the urticaria are rare, and should not 
for an instant deter one from using antitoxin when indicated. They 
are much less common with the refined and concentrated antitoxin in 
use at the present time. 

Real and Alleged Dangers from Antitoxin Injections. — In a few in- 
stances sudden death has followed antitoxin injections, but the evidence 
that antitoxin was the cause of death has not always been conclusive. In 
some of these patients the autopsy has revealed a status lymphaticus 
not before suspected. In this condition the shock of so slight a thing as 
a needle puncture may produce death. There are other cases which do 
not admit of this explanation. Almost all have occurred in patients 
during adolescence or adult life. The symptoms usually come on within 
a few seconds or minutes after the injection and occur quite independ- 
ently of the dose given. Several have followed small immunizing doses 
given to apparently healthy persons, but the majority have been ?uf- 









DIPHTHERIA 1051 

ferers from hay fever or asthma, usually from that form excited by con- 
tact with horses. In some recorded cases the patients had received anti- 
toxin before; in the great majority, however, the sensitiveness to the pro- 
tein of horse serum had been acquired in some other way. The most 
striking symptoms are a rapidly developing dyspnea with cyanosis and 
great prostration. In the most severe cases death may follow in a few 
minutes from respiratory failure ; in those less severe, a gradual recovery 
takes place with no permanent after effects. 

Such experiences are, fortunately, exceedingly rare. No fatalities or 
even severe respiratory symptoms due to the administration of antitoxin 
have been observed since its introduction in the Willard Parker Hospital 
in New York where many thousands of injections of antitoxin are given 
each year. Certainly in children with diphtheria one should not hesitate 
one moment in regard to its use. If the patient gives a history of asthma, 
and inquiry should always be made regarding this, special precautions 
should be employed in giving antitoxin. As concentrated a preparation as 
possible should be used and injected subcutaneously a drop or two at a 
time, at intervals of ten or fifteen minutes. If there is no reaction after 
the first few drops the rest may be injected at once. If there is any reac- 
tion it will not be severe and after a time a drop or two more may be 
given. Thus the whole dose may be given, though it may require much 
time* With a clear history of asthma, injections for immunization may 
well be omitted and the child kept under close observation. If symptoms 
develop after the injection of serum, atropin should be given in full doses ; 
epinephrin and morphin are also useful. In some instances artificial 
respiration has apparently been beneficial. 

Results with Antitoxin Treatment. — Since 1895 the serum has been 
tested on such an extensive scale as the prevalence of diphtheria all over 
the world has made possible, with results so uniformly good that it seems 
quite unnecessary any longer to cite statistics in proof of the value of this 
remedy. 

The beneficial effects of antitoxin may be summed up in the follow- 
ing statements: (1) The percentage mortality from diphtheria in hos- 
pitals both in Europe and in America has been reduced to a little more 
than one-third the previous figures; (2) the proportion of cases now 
requiring operation for laryngeal stenosis has been reduced to about 
one-half; (3) the mortality after tracheotomy has been reduced to one- 
half, and that after intubation to about one-third the former figures; 
(4) but even more convincing is the effect of the Berum treatment upon 
the actual diphtheria mortality of cities and countries where it lias 
been used. 

Convalescence. — After a severe attack of diphtheria convalescence is 
always slow on account of the anemia and the depressing effects of the 



1052 THE SPECIFIC INFECTIOUS DISEASES 

disease. Patients should invariably be kept in bed for at least a week 
after the throat has cleared, and much longer if any tendency to cardiac 
weakness is seen. The pulse should be carefully watched, and irregular- 
ity, intermission, dicrotism, or a weak first sound of the heart, should 
make one apprehensive. An abnormally slow pulse is generally more 
serious than one which is rapid. In such circumstances the patient 
should be kept recumbent and absolutely quiet, since fatal syncope may 
be the result of a violation of these rules. The extreme degree of anemia 
frequently requires that iron be given for a considerable time during 
convalescence. 

Great difficulty is occasionally experienced in getting rid of the 
bacilli in the throat. The tonsillar crypts, the adenoid tissue of the 
rhinopharynx, and the nasal sinuses are the places where the bacilli are 
most likely to remain. Inasmuch as it is now generally made a condition 
of release from quarantine that the throat shall have been shown by 
cultures to be free from bacilli, this becomes a matter of much im- 
portance. Nasal syringing with a very weak solution (1-10,000) of 
bichlorid to which ten per cent solution of glycerin has been added is 
sometimes efficacious. The fluid should be warm and the syringing 
gently done twice daily. The same solution may be used as a gargle. For 
children under four years old a simple salt solution, or a dilute Dobell's 
solution, should be substituted and the gargle omitted. In some ob- 
stinate cases the best procedure is to omit all local treatment and get 
the patient into the open air of the country. When bacilli are very per- 
sistent, as they often are for weeks, their virulence should be tested. In 
the great majority of such cases they are found to be non-virulent and 
further quarantine is unnecessary. When virulent bacilli long persist, 
the question of the removal of the tonsils should be considered. It is 
sometimes successful when all other means of getting rid of the bacilli 
have failed. 

Laryngeal Diphtheria. — Emetics, inhalations of steam, and solvents 
for the membrane, although they all sometimes give relief, are not to be 
relied upon. 

Opinions will always differ as to the time when operative inter- 
ference is called for. One should never wait for general cyanosis, for 
often this does not occur until just before death. It is better to operate 
too early than too late. If, in spite of other measures, the dyspnea in- 
creases steadily, operation should not be deferred longer. Intubation has 
almost universally superseded tracheotomy as a primary operation for 
the relief of membranous laryngitis. Tracheotomy is still needed at 
times for the cases, few in number, in which intubation fails to give 
relief on account of the position of the membrane or for some other 
complication. 






IVI'l 1JATI0X 1053 



Intubation 



Intubation is the introduction of a tube through the mouth into the 
larynx for the relief of laryngeal dyspnea. For the operation, as now 
performed, the world is indebted to the late Dr. Joseph O'Dwyer, of 
Xew York. 

A set of O'Dwyer's instruments consists of seven tubes, an introduc- 
tor, an extractor, a mouth-gag, and a gauge. The tubes are made of 
hard rubber and lined with gold-plated metal. So carefully did O'Dwyer 
perfect his instruments that nothing of importance has been added by 
others. It is interesting to note that nearly all the modifications which 
have been suggested since his first publication had already been tried 
by him and discarded. Xo one thing is more essential to success with 
intubation than properly constructed instruments. The operation is 
not difficult if one has had practice on the cadaver. Without this it 
should not be attempted. The tube is selected according to the age of 
the patient, this being indicated on the gauge. A very large child will 
often require a tube of larger size than his age would call for. 

Introduction of the Tube. — Either one of two positions may be 
employed, the choice depending upon the preference of the operator. 
In one the child is seated upon the lap of a nurse while his head is 
steadied by a second assistant standing behind. In the other position the 
child lies upon his back upon a table, his head being steadied by an 
assistant. In both positions the arms should be pinioned to the sides by 
a sheet. In the recumbent position the child can be held more firmly; 
it has also the advantage of dispensing with one assistant, and in an 
emergency with both of them. The tube is attached to the introductor, 
and the gag is inserted at the left angle of the mouth and opened as 
widely as possible. The attempts at introduction must be made quickly, 
for during them respiration is practically arrested. Several short at- 
tempts are always better than a single prolonged one. Very little force 
is ordinarily required in introducing the tube, that used in passing a 
catheter being a good general guide. In cases of subglottic stenosis, 
however, quite a little force may be necessary. 

The index finger of the left hand is used as a guide in introduction. 
This is passed well back into the pharynx, then brought forward until a 
hard nodule — the upper border of the cricoid cartilage — is encountered. 
This is the best of all landmarks, since the soft parts are often distorted 
by swelling. Directly in front of the cricoid cartilage may be felt the 
epiglottis and the opening of the larynx, which are readily recognized 
after the touch has become somewhat educated. The epiglottis is drawn 
forward and the tube is passed along the palmar surface of the left index 
finger, by which it is guided into tbe larynx; it is then pushed off the 
35 



1054 THE SPECIFIC INFECTIOUS DISEASES 

introductor by a thumb-piece attached to its handle. When it is certain 
that the tube is in position, and the patient breathes properly, the loop 
of silk attached to the head of the tube is cut off and pulled through, 
the removal of the tube being prevented by placing the left forefinger 
upon its head. The silk is not usually left attached unless there is evi- 
dence of loose membrane below the tube. It may be desirable to leave 
the silk attached in case no one is within reach who is able to remove 
the tube should it become obstructed. The child's arms and hands should 
then be secured to prevent him from seizing it himself. When not re- 
moved, the silk is fastened to the cheek by a piece of adhesive plaster. 
The tube is known to be in place, first, by the hissing breathing sounds, 
somewhat similar to what is heard when the trachea is opened ; secondly, 
by a severe paroxysm of coughing, which is usually excited by a tube in 
the larynx; thirdly, by the relief of the dyspnea. If this relief is not 
very apparent the physician may still be in doubt as to whether the tube 
is in the larynx or the esophagus. If in the former, it can not be pushed 
down by the finger without depressing the larynx with it; and by in- 
troducing the finger into the pharynx, the posterior wall of the larynx 
can be felt between the finger and the tube. The most common mistake 
made is to pass the tube into the esophagus. This sometimes happens 
because the position of the child's head is improper — too far forward or 
too far backward — but more often because the operator has not been quite 
sure of his landmarks. If this has occurred, there is no relief to the 
dyspnea, no hissing sound, and the tube can be pushed down indefinitely. 
When this condition is recognized, the tube is withdrawn by the loop of 
silk and after a few moments a second attempt made. 

False passages in the larynx are most frequently made by employing 
too much force or because the operator has worked at the angle of the 
mouth instead of keeping in the median line. The tube usually goes 
into one of the ventricles of the lar} T nx and may be pushed quite through 
the larynx into the cellular tissue. This is not very likely to happen, 
however, unless undue force has been used. The production of a false 
passage is recognized by the fact that, although the tip of the tube can 
be felt to enter the larynx, the tube does not descend, but projects above 
the epiglottis. 

False membrane which has become loosened is sometimes crowded 
down by the tube and obstructs the larynx just below it. This is one of 
the most serious accidents that may occur, but fortunately it is not a 
frequent one. It is more likely to happen when the disease has existed 
for several days than in recent cases. The tube may be in place in the 
larynx as shown by all the signs above mentioned, except relief of the 
dyspnea. In such a case the immediate withdrawal of the tube is neces- 
sary, it being often followed by the discharge of masses of loose mem- 



INTUBATION 1055 

brane. This is aided by the administration of half a teaspoonful of pure 
whisky or brandy to excite a strong cough. Artificial respiration may be 
required, and if there is no relief by any of these means tracheotomy is 
indicated. Asphyxia is sometimes produced by prolonged and injudicious 
attempts at intubation. 

After-treatment. — So far as the tube itself is concerned no treat- 
ment is required. The original disease is to be treated as before. The 
operation has removed only one danger from the patient, viz., that of 
asphyxia from mechanical obstruction of the larynx. A good expulsive 
cough should occur after the tube is in place. This is necessary to 
clear the tube of mucus, as the pharynx and larynx are generally rilled 
with it as a result of the manipulation.' 

The child should not be allowed to lie upon his face, nor should he 
be held over the nurse's shoulder face downward, for in either position 
a slight cough is enough to expel the tube. Nursing infants may some- 
times continue at the breast after the operation; ordinarily they have but 
little difficulty in swallowing. Older children often experience consid- 
erable trouble in taking liquids. This may be overcome by the device sug- 
gested by Casselberry, of having the patient's head lower than his body 
while he drinks. When fluids cause excessive coughing, or at other 
times when they can be taken only with the greatest difficulty, they 
may be given through a nasal tube or one passed through the mouth. 
Semi-solid articles, such as condensed milk, wine jelly, cornstarch, ice 
cream, or scrambled eggs, may be well taken when fluids are not. 
Feeding is always easier after the first day or two, and patients who 
wear a tube for chronic disease soon experience no trouble whatever, 
showing that the difficulty depends more upon the inability to co- 
ordinate the movements of the muscles of deglutition when the tube is 
in place than upon mechanical causes, for the head of the tube is ef- 
fectually covered by the epiglottis. 

When the tube is removed by extubation or coughed up, the dyspnea 
does not usually return for two or three hours, but may come back at 
once. It may happen that the tube is coughed up and not seen by the 
nurse, or it may be coughed up and swallowed by the child. When 
called because of dyspnea after operation, the physician should make a 
digital examination of the pharynx to discover if the tube is still in 
place. Swallowing the tube generally causes no harm to the child, for 
tubes have repeatedly passed through the intestines. Should the tube 
be coughed out at any time its introduction should be delayed until 
dyspnea returns. 

Tt sometimes happens that the tube is coughed out soon after its 
introduction because too small a size has been u^><\. Af. other limes 
this occurs repeatedly even with tubes of the proper size. Such cases 



1056 THE SPECIFIC INFECTIOUS DISEASES 

are probably due to paralysis of the laryngeal muscles. As patients 
in such circumstances are unable to breathe for even a few minutes 
without the tube it is. usually necessary with repeated self extubation to 
perform tracheotomy. 

The entrance of food into the bronchi through the tube is a danger 
that does not exist, and bronchopneumonia following intubation does 
not depend upon this cause. 

Deep ulceration at the head of the tube rarely occurs, provided prop- 
erly made tubes are employed, but superficial ulceration is almost in- 
variably produced at the base of the epiglottis and in the trachea, at 
the lower end of the tube. Deep ulcers extending to the tracheal rings 
may occur in ill-conditioned children, usually in connection with other 
complications serious enough to cause death. 

Spontaneous descent of the tube into the larynx is almost impossible, 
and it can not be crowded down without using considerable force and 
severely lacerating the larynx. 

Sudden blocking of the lower end of the tube by membrane loosened 
from the trachea or bronchi occasionally occurs. The usual result of 
this is the immediate expulsion of the tube by coughing, the discharge 
of the loose membrane following. This condition is one of the safety 
valves of the operation. One of the strong points in favor of intubation 
is that the forcible cough which the patient is able to make on account of 
the narrow opening of the tube, often enables him to expel large accu- 
mulations of mucus, and even membrane, more readily than through a 
much larger tracheal opening. 

The period for which the tube is required varies much in different 
cases. It has been materially shortened by the use of antitoxin. The 
average time of wearing the tube is about five days, and in many it can 
be dispensed with in two or three days. An attempt should be made 
to have the child go without the tube whenever the temperature reaches 
normal. If complications are present that still cause fever extubation 
should not be deferred j)eyond the fifth or sixth day. The majority of 
cases do not require re-intubation. If this is necessary, extubation should 
be done again in three or four days and repeated thereafter at this in- 
terval until the tube is no longer necessary. If, after several weeks the 
tube cannot be dispensed with the treatment described later for retained 
intubation tubes should be adopted. 

Removal of the Tube — Extubation. — This is rather more difficult 
than its introduction. The general arrangement of the patient and 
assistants is the same as for introduction. The left index finger is placed 
upon the head of the tube, which is steadied externally by the thumb of 
the same hand. The beak of the extractor is introduced within the open- 
ing of the tube, its jaws are then separated by pressure upon the lever 



INTUBATION 1057 

at the handle, and the instrument withdrawn, very slight force being 
required. 

The tube is first removed tentatively, the physician waiting to see if 
dyspnea returns. It is well to give a full dose of morphin an hour 
before the removal of the tube, since this operation is almost invariably 
followed by a marked degree of laryngeal spasm which lasts for ten or 
fifteen minutes. To avoid the production of vomiting and the entrance 
of food into the larynx, food should not be given for three hours previ- 
ously. If dyspnea does not return in the course of three or four hours, 
the probabilities are that the tube will no longer be required. It is excep- 
tional that the patient has great difficulty in dispensing with the tube, 
as so often happens after tracheotomy. 

The only objection of much force urged against intubation is that 
asphyxia may be produced by crowding down loose membrane into the 
larynx. This is an infrequent accident; should it happen, and the 
asphyxia not be relieved by removing the tube and inserting another, 
tracheotomy may be performed. 

There is always some degree of hoarseness following intubation, but 
in the majority of cases it disappears within a week, occasionally it con- 
tinues as long as three or four weeks, but it is very rarely if ever perma- 
nent. The duration of the aphonia seems to have little relation to the 
length of time the tube is worn, unless this is many weeks. 

Experience has clearly proved that intubation relieves the dyspnea 
due to laryngeal stenosis promptly, efficiently, and certainly; it does this 
without many of the dangers and objectionable features of tracheotomy, 
while at the same time it does not deprive the patient of any essential 
advantage which tracheotomy affords. 

Retained Intubation Tubes — Prolonged Intubation. — Difficulty is 
experienced in dispensing with the intubation tube much less frequently 
than with the cannula after tracheotomy; yet when this condition occurs 
it is the cause of much concern and even danger. Trouble of this sort 
is seen in about five per cent of the cases of intubation. In the majority 
of these the patient is able to do without the tube in a few weeks, and 
such cases require very close attention, but no special treatment other 
than the substitution at times of a special O'Dwyer tube with an extra 
large "retaining swell." But occasionally there are met with cases in 
which every effort to dispense with the tube proves futile. Although 
the children breathe well with the tube in place, still if it is removed 
or expelled by coughing, in a short time, varying from a few minutes to 
several days, the dyspnea returns with such severity that the tube must 
be replaced to prevent asphyxia. Inasmuch as these patients sometimes 
expel the tube several times a day. surgeons have often resorted to trache- 
otomy to avert the danger of suffocation, which might easily occur if no 



1058 THE SPECIFIC INFECTIOUS DISEASES 

one were at hand who could replace the tube. This operation, however, 
gives only temporary relief. Many of these children, after wearing 
tubes of one sort or another for years, ultimately die from some accident 
connected with the tube or from pneumonia. 

The, causes and the exact pathological condition underlying this dif- 
ficulty are subjects regarding which there has been much difference of 
opinion. The cause of the returning dyspnea is probably subglottic 
swelling and edema which occur in tissues which are the seat of chronic 
inflammation, as soon as the pressure of the tube is removed. In a few 
cases a cicatricial condition, the result of previous ulceration, has been 
found; but it is doubtful if granulations, so frequent a cause of retained 
cannula after tracheotomy, play an important part. The chronic in- 
flammation of the mucous and submucous tissues of the subglottic region 
of the larynx which produces the symptoms, is aggravated by a faulty 
tube or a clumsy operation, but it may occur under the most favorable 
conditions. 

For the relief of this condition, O'Dwyer advised in recent cases the 
application of astringents by means of an intubation tube coated with 
gelatine with which some astringent was combined. For those patients 
who cough out the tube frequently, tracheotomy is at times a necessity 
to prevent sudden death. But this does not affect the original condition, 
for the same difficulty exists in doing without the tracheal cannula. The 
operations of laryngotomy, curetting, etc., have been such signal failures 
as to discourage one from repeating them. 

The most successful method of treatment thus far proposed is that 
of Sogers, which consists in increasing intra-laryngeal pressure by the 
insertion of larger and larger intubation tubes. This is not to be adopted 
until long after all acute symptoms have subsided. The first tube used 
is as large a one as can be introduced without force ; after a few weeks, 
the next larger size, and after a longer interval, possibly a still larger one. 
When the very large tube has been worn for several weeks one is usually 
able to dispense with all tubes. 

True cicatricial stenosis may best be relieved by opening the trachea 
and dilating from below, and afterward inserting an intubation tube. 
When there is complete destruction of the cricoid cartilage, as sometimes 
occurs, tracheotomy is the only remedy, but this is only palliative, as the 
tube must be worn permanently. 



TYPHOID FEVER 105U 

CHAPTER IX 
TYPHOID FEVER 

Typhoid fever is an acute infectious disease due to a specific organ- 
ism — Eberth's bacillus. It may affect the fetus in utero, or the newly- 
born child, and it is seen in infancy and throughout childhood. 

Paratyphoid. — This is a disease in all respects similar to typhoid fever 
and one that cannot be differentiated from it except by bacteriological 
examination. It may be due to organisms known as paratyphoid "A" 
and paratyphoid "B." This disease is much less common than true 
typhoid, but small epidemics from time to time appear. These are 
usually due to paratyphoid "B" which, in this country at least, is much 
more common than paratyphoid "A" There are no clear distinguishing 
features between them. Widal reactions in these infections and in true 
typhoid somewhat overlap one another; but they may, in certain in- 
stances, be fairly distinct so that from the Widal alone the diagnosis can 
be suspected. Xot many autopsies have been reported after infection 
with these organisms; but in general the lesions do not differ markedly 
from those of true typhoid. 

Fetal Typhoid. — When a pregnant woman develops typhoid fever, 
infection of the child in utero is a frequent but not an invariable occur- 
rence. The fetal form of the disease is a general blood-infection, since 
the intestines are not functionally active. The most common result is 
death of the fetus and consequent abortion ; but the child may be born 
alive still suffering from the infection. On account of the infant's feeble 
resistance death usually occurs. 

Infantile Typhoid. — Modern methods of diagnosis, particularly blood 
cultures, have answered the question, long discussed, as to the frequency 
of infantile typhoid. It is a relatively rare disease. In over 14,000 
admissions to the Babies' Hospital, New York, covering a period of 
thirteen years, but eleven cases of typhoid were observed under two years 
of age and but five cases of one year or under, the youngest case 
observed being in a child eight months old. In Philadelphia, where 
tbere lias been much more typhoid generally than in Xew York, Griffith 
reports under his personal observation or in Hie Children's Hospital 
forty-five cases under two years and nine under one year; his youngesl 
cases were aged three, five, and nine months respectively. Typhoid has 
been seen by Miirebison at six months ami by Ogle at four and a half 
months, the diagnosis being, in both instances, confirmed by autopsy. It 
is during epidemics that most of the infantile eases arc Been, but eveu 
in epidemics it is surprising that so few infants are attacked. 



1060 THE SPECIFIC INFECTIOUS DISEASES 

Typhoid in childhood is by no means rare, but it is not until after 
the fifth year that it can be said to occur frequently. The following 
figures, embracing groups of cases reported by eight writers, represent the 
relative frequency with which the disease is- seen at the different ages: 
Of 970 cases, eight per cent occurred under five years, forty-two per cent 
between five and ten years, and fifty per cent between ten and fifteen 
years. 

Typhoid fever is almost invariably contracted by drinking water or 
milk which contains the germs of the disease. The infrequency of 
typhoid even in infants who are artificially fed is explained, in part at 
least, by the fact that most of the water and a large part of the cow's 
milk taken have been previously boiled, or heated in some manner. 

Lesions. — In a general way these resemble those of adults except in 
severity. In a considerable number of the cases the pathological process 
in the intestines does not go on to ulceration ; and when ulcers form they 
are seldom large or deep, and perforation is very rare. Montmollin gives 
the following facts concerning twenty-three autopsies, most of them, how- 
ever, being in children over eight years old : ulcers were present in seven- 
teen cases ; they were situated in the lower ileum in sixteen, and in ten 
they were only there; in the ascending colon in nine, and only there in 
one case; perforation occurred in three cases, in every instance in the 
lower ileum. Autopsies made upon infants may show even less severe 
intestinal lesions than those mentioned. In fact, some cases in which 
the clinical diagnosis was beyond question, have shown only moderate 
redness and swelling of Peyer^s patches, the solitary follicles and the 
mesenteric lymph nodes — lesions which are exceedingly frequent in cases 
of simple diarrhea. In a doubtful case such post mortem findings do not 
establish the diagnosis of typhoid. Indeed, they prove nothing unless 
cultures from the intestinal contents, the mesenteric glands, or other 
organs, show the typhoid bacillus. Enlargement of the spleen is prac- 
tically constant. The degenerative changes in the heart, the kidneys, and 
the liver are much less frequent and generally less severe than in adults. 

Symptoms. — The peculiar features of typhoid in early life are seen 
only in children under ten years old ; for after this time the disease does 
not differ essentially from the adult type. In brief, the typhoid of early 
childhood may be described as a fever characterized more often by nerv- 
ous symptoms than by intestinal symptoms. 

Onset. — A sudden onset with well-marked symptoms — fever, pros- 
tration, vomiting, etc. — is not uncommon; in fact, it is more frequently 
seen than the insidious beginning, with lassitude, headache, coated 
tongue, anorexia, and gradual rise in temperature. In cases developing 
abruptly it often appears as if an acute indigestion had been the means 
of precipitating the attack. The most frequent initial symptoms are 



TYPHOID FEVER 1061 

vomiting, diarrhea, prostration, headache, anorexia, and fever. Chills 
are rare; occasionally there is abdominal pain or tenderness. Epistaxis 
occurs as an early symptom much less frequently than in adults. 

Condition of the Bowels. — There is no constant relation between the 
severity of the intestinal lesions and the condition of the bowels. Tak- 
ing large groups of cases together, diarrhea is present in only about half 
the total number. It is rarely profuse, from two to four discharges a day 
being the average. The appearance of the stools is seldom character- 
istic; they are usually thin and fluid, often containing mucus. Consti- 
pation may be present at the beginning only, or throughout the attack. 
Tympanites is generally moderate, and is often entirely absent; it usu- 
ally accompanies constipation. Marked iliac tenderness and gurgling 
are infrequent. 

Spleen. — By the end of the first week this is usually found to be en- 
larged to a sufficient degree to be recognized by palpation. In most cases 
it extends but an inch or an inch and a half below the ribs, but at times 
it may be three inches or more; persistent enlargement may indicate 
that the disease is not at an end even though the temperature has reached 
the normal, and a relapse should be expected. 

Eruption. — It is the experience of nearly all who have seen much of 
typhoid in children that the eruption is less constant, usually less abun- 
dant, and less characteristic than in adults, but appears rather earlier. 
We have, however, seen it so abundant as to suggest measles. The typical 
eruption consists of small, scattered, rose-colored spots, which appear 
chiefly or solely upon the abdomen at the beginning of the second week. 
They come in successive crops, each one of which generally lasts three 
days, the whole duration of the eruption being about ten days. 

Prostration, Emaciation, etc. — As a rule the prostration is quite suffi- 
cient to keep a child in bed after the first few days. The general weak- 
ness after this time is in direct proportion to the height of the tempera- 
ture. Loss of flesh is steady and usually marked ; and in a prolonged 
attack there may be emaciation. 

Temperature. — In the cases with a gradual onset, the typical tem- 
perature curve is one which rises steadily for from two to seven days, 
fluctuates within the limits of one to three degrees during the second 
week, and steadily declines during the third week, reaching the normal 
on the average at the end of the third week. In cases with an abrupl 
onset, the temperature rises at once to from 102.5° to 105° F., but sub- 
sequently may run the same course as in the firs! group. 

The following are the most important variations from the tempera- 
ture curve of adults: the initial rise is much more; frequently rapid; 
during the second week the remittent character is less marked; the 
average duration is shorter. In young children the proportion of cases 



1062 



THE SPECIFIC INFECTIOUS DISEASES 



in which the fever lasts only from eight to fourteen days is quite large 
(Fig. 171). After the age of ten years the type of the fever is much 
like that seen in adults. The maximum temperature in the mild cases 
is 103° pr 104° F.; in the severe ones it often reaches 105° or 106° F., 

but rarely goes above this 
point. The range is usually 
higher than in adult cases 
of the same severity. At 
the beginning of convales- 
cence a subnormal tempera- 
ture is very frequent, and 
by many writers is consid- 
ered to be the rule. A sec- 
ondary rise is most fre- 
quently due to errors in 
diet, but may occur from 
the development of compli- 
cations. A sudden fall often 
indicates either perforation 
or intestinal hemorrhage. 
Relapses occur in approximately 10 per cent of the cases. They follow 
about the same course as in adults (Fig. 172). 

Nervous Symptoms. — In many cases these are more prominent in 
severe cases than the intestinal symptoms, and are directly proportionate 
to the height of the temperature. The extreme nervous symptoms belong- 



DAY 

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Fig. 171. — Typhoid Fever of Short Duration 
in a Child Thirteen Months Old. Spleen 
enlarged; eruption typical; no diarrhea and 
only moderate abdominal distention. There 
were two other cases in the family, all being 
due to the same cause — infected milk. (After 
Northrup.) - 



DAY 8 9 10 11 12 13 14 15 10 17 18 19 20. 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 30 37 38 39 40 41 42 43 


t 

I 
z 
111 

<r 

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104°^^ 1 1 J 


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S> i jll_ f ^nf. 


»° A B-N- 3% ttrs^-, 


V Vj L^ r ^2u = ^ 


^ w r\^ 





Fig. 172.— Typhoid Fever with Relapse. Child two and a half years old; early tem- 
perature high and symptoms typical; natural fall on fourteenth day; rise on seven- 
teenth day apparently due to otitis; relapse on twenty-fourth day, with fresh erup- 
tion and return of splenic swelling which had disappeared. Temperature was sub- 
normal at the end both of primary and secondary fever. 



ing to the typhoid state in adults are rare in childhood, except in patients 
over ten years old. Headache and mild delirium at night are very fre- 
quent, the former being seen in the majority of cases. Young children 
are usually dull, apathetic, and often in a state of semi-stupor. Oc- 
casionally the disease may closely simulate meningitis. The 



nervous 



TYPHOID FEVER 1063 

symptoms are usually most severe in the second, or early in the third 
week, and subside as the temperature declines, but may continue for 
several days thereafter. Exaggerated reflexes and ankle clonus are not 
infrequent and may persist well on into convalescence in severe cases. 

Pulse. — This is increased in frequency, but not to the degree that 
is seen in most diseases of childhood with a similar elevation of temper- 
ature. The force and rhythm of the pulse are usually good, irregularity 
and dicrotism being rare in children as compared with adults. 

Urine. — A small amount of albumin is found in the urine of most 
of the severe cases at the height of the disease, and is due to acute renal 
degeneration ; but a marked degree of nephritis is infrequent. In from 
one-fourth to one-third of the cases typhoid bacilli are found in the 
urine, generally in pure culture. They usually appear in the latter part 
of the disease, the second or third week, and may continue for months 
or even years. They are sometimes accompanied by evidence of cystitis 
or nephritis. Their number is in some cases so large as to render the 
urine turbid; in others they give no indication of their presence. Elir- 
lich's diazo reaction is usually present at the height of the fever. 

Blood. — The characteristic blood picture in typhoid is a low leucocyte 
count, generally under 10,000, accompanied usually by a slightly increased 
proportion of lymphocytes. Blood cultures, with great uniformity, show 
the bacilli even in the first week of the disease. These usually have dis- 
appeared from the blood by the third week. 

Intestinal Hemorrhage. — Of 946 collected cases, mainly from hospital' 
reports, intestinal hemorrhage occurred in thirty, or about three per 
cent; the majority of these were in children over ten years old. Of 
twenty-four collected cases of hemorrhage in children, ten terminated 
fatally. The youngest case of this nature which has come under our own 
notice was in a child of four and a half years.. 

Intestinal Perforation. — This is even more rare than hemorrhage. 
In 1,028 collected cases, this accident occurred but twelve times, or in 
1.1 per cent. Perforation is indicated by a sudden fall in the tem- 
perature, with collapse; usually there is vomiting and the rapid devel- 
opment of tympanites with leucocytosis. 

Complications and Sequelae. — The complications of typhoid in early 
life are infrequent and usually mild. Bronchitis is present in most of 
the severe cases. Pneumonia has been noted in nine per cent of the cases 
reported by various authors. Both serous and purulent effusions into 
the chesl arc occasionally seen, and sometimes abscess of the lung. 

Complications referable to tbe nervous system are not very frequent, 
but are of much interest. Meningijtifl LS extremely rare. Morse lias 
collected twenty-one cases of apliasia, in l\v<> of which it was clearly due 
to embolism; in the remainder, however, it apparently was not dependent 



1064 THE SPECIFIC INFECTIOUS DISEASES 

upon any organic lesion. In two-thirds of the cases it came on during 
convalescence, and in nearly all complete recovery occurred after an 
average duration of three weeks. Aphasia usually followed a severe type 
of the disease, and in most of the cases was not accompanied by any other 
paralysis or by mental disturbance. Insanity is a rare sequel of typhoid 
in children, the usual type being acute mania. Recovery is usually com- 
plete. Chorea is seen rather oftener than after the other infectious dis- 
eases. 

Otitis is not an infrequent complication, occurring much oftener than 
in adults. It is principally seen in young children and during the cold 
season. Among the less frequent complications may be mentioned : paro- 
titis, which is usually suppurative and is seen in septic cases; abscess 
of the liver, examples of which have been reported by Bokai, Asch, and 
others; gangrenous inflammation of the mouth or genitals; pericarditis, 
endocarditis, and peritonitis, suppurative inflammations of joints, mul- 
tiple abscesses and furunculosis. Tuberculosis of the lungs or bones not 
infrequently follows typhoid. 

Diagnosis. — The diagnostic symptoms of typhoid are, the Widal blood 
reaction, the discovery of the bacilli in the blood, urine or feces, the erup- 
tion, the course of the temperature, the enlargement of the spleen and the 
abdominal symptoms — diarrhea, tympanites, hemorrhage, and perfora- 
tion. 

The Widal reaction is present at some period in from ninety-five to 
ninety-eight per cent of the cases, and .'thus becomes the most valuable 
single symptom for diagnosis. It is seldom obtained before the seventh 
day and frequently not before the tenth or twelfth; it may not be present 
until convalescence or a relapse. Eepeated tests should always be made 
i£ the first reaction is negative or doubtful. The reaction is therefore 
of much less value for an early than for an exact diagnosis. A positive 
reaction may be present if the patient has previously had typhoid, some- 
thing much less likely to be the case with children than with adults ; in 
rare instances it has been obtained in other diseases or in health when no 
history of previous typhoid existed. Both these conditions, however, are 
very exceptional, and a positive reaction may as a rule be taken to estab- 
lish the diagnosis. 

Typhoid bacilli may be demonstrated in the stools by culture in a 
large proportion of the cases. They are found in the urine, usually in 
the latter part of the disease, in about one-third the cases. Their dis- 
covery in either of these discharges is conclusive evidence of previous or 
existing typhoid. An examination of both urine and feces should, if 
possible, be made in all doubtful cases. 

The course of the temperature is an important aid to diagnosis, but 
alone is not to be depended upon, The characteristic feature is a fever 



TYPHOID FEVER 1065 

which continues for two, three, or four weeks, and subsides gradually. 
The variations from the adult type have already been mentioned, also 
the frequency of the eruption, the enlargement of the spleen, and the 
abdominal symptoms. "We are not warranted in making the diagnosis 
of typhoid, if repeated tests fail to show the Widal reaction or if the 
eruption and splenic enlargement are absent, and no bacilli can be 
demonstrated in the blood or discharges, no matter what the course of 
the temperature may be. 

One should hesitate to make the diagnosis of typhoid in a child 
under two years old, unless typhoid is prevalent in the community. The 
great majority of sporadic cases reported as occurring in infancy are 
probably not typhoid. After the fifth year the disease is more frequent, 
and its symptoms in general resemble those seen in adults, except in 
severity. 

A differential diagnosis is to be made from malarial fever, ileocolitis, 
meningitis, tuberculosis, and from other ill-defined continuous fevers of 
unknown origin. From malarial fever the diagnosis is to be made by 
the temperature curve, the organisms in the blood, and the effect of 
quinin. In most of the cases of malaria the temperature will be found 
to touch the normal at some time in the twenty-four hours. The admin- 
istration of full doses of quinin is a diagnostic test of much practical 
importance; an irregular or remittent fever which yields promptly to 
quinin is most certainly not typhoid. 

Ileocolitis and typhoid fever are not often confounded. The former 
is chiefly seen in the first three years of life, a time when typhoid is rare. 
The intestinal symptoms of ileocolitis are marked even though the tem- 
perature is not high, and they are altogether more severe than is usual 
in typhoid; while enlargement of the spleen, tympanites, and the erup- 
tion are not present. 

The cerebral symptoms of typhoid may be difficult to distinguish from 
meningitis, unless one has watched their development. Irregular respira- 
tion, a slow, irregular pulse, localized paralysis and complete coma are 
seldom, if ever, seen in typhoid, and a retracted abdomen very rarely, 
while the enlarged spleen and the peculiar eruption are not seen in men- 
ingitis. 

General tuberculosis very often resembles typhoid so closely that a 
differential diagnosis is almost impossible from symptoms alone until 
local signs of tuberculosis have appeared, usually in the lungs. The 
cutaneous test is in most cases a valuable aid. 

Prognosis. — Of 2,623 eases in children, collected from the reports of 
twelve different writers, the mortality was :>. I per cent. These arc. how- 
ever, almost all taken from hospital reports, where as a rule the mildest 
cases are not brought for treatment. The mortality of the disease in 



1066 THE SPECIFIC INFECTIOUS DISEASES 

children over three years old probably does not exceed three or four per 
cent. Death seldom occurs from the disease itself, but usually from some 
accident or complication, the most frequent being pneumonia and intes- 
tinal hemorrhage or perforation. Griffith's collection of cases occurring 
in infancy indicates a much higher mortality for this period. The death- 
rate for the first year reached nearly fifty per cent. 

Treatment. — The usually low mortality of this disease shows how 
successful all methods of treatment are likely to be considered. In the 
great majority of cases very little active treatment is required. Every 
patient with typhoid should be put to bed and kept there during the 
febrile period, and a few days beyond it, no matter how mild the attack 
may be. The diet should consist of sterilized milk, broths, cereal gruels, 
milk toast, soft eggs, custard, and plain ice-cream. These articles should 
be given liberally every four or five hours, but not pushed beyond the 
desire of the patient. Milk may be diluted, and kumyss or buttermilk 
may be substituted for it if the stomach is irritable. Plenty of water 
should be given. Solid food should not be allowed until the temperature 
is normal. 

Both the urine and feces should be immediately and thoroughly dis- 
infected by a solution of carbolic 1:20. If the movements are in a 
chamber or a bed-pan they should be covered with this solution for at 
least six hours before they are thrown into the water-closet. If napkins 
or diapers are used, they should be soaked in some eif ective antiseptic 
solution for twelve hours and then thoroughly boiled. Sheets stained 
by discharges should be treated in the same way, and all bed-linen should 
be boiled for an hour, apart from the washing of the family. The 
efficiency of hexamethylenamin (urotropin) in removing typhoid bacilli 
from the urine seems now to be well established. It should be given at 
the close of the attack in doses of three to five grains, three times a day, 
and continued for a week or ten days. 

Diarrhea calls for treatment only when the movements exceed four 
or five in twenty-four hours. If no more than this number are present, 
they should not be interfered with. Opium and bismuth are undoubt- 
edly the best means for controlling excessive diarrhea, but care should 
be taken that they are not pushed to the degree of inducing constipa- 
tion. 

Constipation early in the disease may be relieved by castor oil, but all 
active purgation should be avoided. Later in the disease irrigation of 
the colon with tepid water is better than anything else. On the whole, 
constipation is more troublesome to overcome than diarrhea. 

Tympanites does not often require treatment; it may be relieved by 
turpentine stupes, by a glycerin suppository, or a small glycerin injection 
(one toaspoonfnl of glycerin to four ounces of water), or, better still, by 



TUBERCULOSIS 1067 

the use of the rectal tube. If the distention is continuous and extreme it 
may be necessary to stoj) all food for several hours until it is relieved. 

Whenever the temperature remains above 101° F., antipyretic meas- 
ures are indicated. In mild cases cold or tepid sponging is generally 
sufficient. In those which do not yield to such measures, baths may be 
employed. Xot all children bear baths well, and considerable discretion 
should be used in employing them. One should be guided quite as much 
by the effect upon the pulse and the nervous system as by the tempera- 
ture. The best method is usually the graduated bath ; the child is placed 
in the tub with the water at a temperature of 95° or 100° F. ; this is 
gradually lowered to 95°, 90°, or even 85° F., but seldom lower. The 
body should be actively rubbed while the child is in the bath, to prevent 
shock and cardiac depression. The pack may be substituted for the 
bath when circumstances make the latter impracticable. The bath or 
pack should be repeated in an average case in from three to six hours. 

The milder nervous symptoms — headache, restlessness, sleeplessness, 
etc. — may be relieved by an occasional dose of phenacetin, either alone 
or in combination with the bromids, or by cool or tepid sponging; the 
more severe ones usually occur with high temperature, and are best con- 
trolled by the bath. 

Stimulants in most of the cases are not called for. They are to be 
given according to the indications afforded by the pulse, the first sound 
of the heart, and the child's general condition. They are seldom needed 
earlier than the end of the second week. Intestinal hemorrhage calls 
for absolute quiet, morphin hypodermically, and an ice-coil to the abdo- 
men, nothing being given by mouth except stimulants and possibly opium. 
Intestinal perforation is successfully treated only by early laparotomy. 



CHAPTER X 
TUBERCULOSIS 



Tuberculosis is an infectious, communicable disease due to the 
bacillus tuberculosis of Koch. It may be local or general, and may in- 
volve any organ and almost any structure in the body. 

Etiology. — Age and Frequency. — No age is exempt from tuberculosis. 
It was formerly believed that the disease was rare in infancy, but recent 
observations have shown the opposite to be the case. 

Statistics taken chiefly from three New York institutions where only 
infants and young children are received give the following figures for 
382 cases of tuberculosis, the diagnosis being confirmed by autopsy in 



1068 



THE SPECIFIC INFECTIOUS DISEASES 



nearly every instance: In the first year there were 1G0 cases, and of 
these 67. were nnder six months, 10 of which were under three months 
of age. The frequency of tuberculosis appears to increase steadily as 
age advances, as shown by the following table, in which results found by 
Yeeder and Johnston in St. Louis are compared with those of Hamburger 
and Monti and von Pirquet in Vienna. The cutaneous or intracutaneous 
test was applied in all instances. Cases of clinical tuberculosis were ex- 
cluded. 



Age (years). 


Veeder and Johnston, 
St. Louis. 


Hamburger and Monti 
Vienna. 


von Pirquet, 
Vienna. 


No. of 

Cases. 


Percentage of 
Tuberculosis. 


No. of 
Cases. 


Percentage of 
Tuberculosis. 


No. of 
Cases. 


Percentage of 
Tuberculosis. 


Under 1 


202 
109 
163 
172 
152 
126 
107 
94 


1.5 
5.5 

19 

23 

29 

30 

34 

38 


23 
46 
131 
113 
76 
61 
48 
34 



9 
27 
51 
61 
72 
94 
94 


388 

89 

162 

1-343 
J 147 





1 to 2 





2 to 4 


13 


4 to 6 




6 to 8 


37 


8 to 10 




10 to 12 


70 


12 to 14 








1,125 


21 


532 


51 


1,129 


22. 5 1 



a The total incidence of tuberculosis is small on account of the large number 
of infants tested. 

From the facts at hand it would seem that the percentage of children 
with tuberculosis is much greater in Europe than in this country. The 
following table gives figures for three institutions in New York, as com- 
pared with data taken from Vienna and Munich. The difference in the 
ages of the children makes comparison difficult. 



Frequency of Tuberculosis as Shown by Autopsies 






No. 


No. Show- 


Percentage 


Institution. 


Age of Patients. 


of 


ing Tuber- 


Showing 






Autopsies 


culosis. 


Tuberculosis. 


N. Y. Infant Asylum . . 


Nearly all under 2)4, years 


726 


56 


8 . per cent 


Babies' Hosp., 1st series 


« u « 3 « 


1,000 


168 


16.8 " 


Babies' Hosp., 2d series 


tt a tt o tt 


1,320 


178 


13.5 


N. Y. Foundling Hosp. 


" " " 3 " 


1,000 


136 


13.6 " 


Miiller — Munich 


Children of all ages 


500 


200 


40.0 


Hamburger — Vienna. . 


All ages up to 14 years .... 


848 


335 


40.0 " 


it a 


f Including only children \ 
\ of 2 years and under. / 


497 


120 


24.4 " 



These percentages are not to be taken to represent the occurrence 
of tuberculosis in the community generally, but only its frequency in 



TUBERCULOSIS 1069 

the class which furnishes hospital and institution inmates. Kor are 
these figures to be interpreted as showing the percentage of active tuber- 
culosis. In the cases showing tuberculosis at autopsy nearly one-third 
of the number died from other diseases, tuberculosis being latent and 
its existence being discovered only post mortem. Likewise in nearly 
one-fifth of the cases giving positive skin reactions there were no evi- 
dences of active tuberculosis. 

Predisposing Causes. — These include all the conditions which bring 
about a diminished resistance of the body to tuberculous infection. This 
susceptibility may be inherited, as when parents have suffered from tu- 
berculosis or other constitutional disease — syphilis, alcoholism, etc. It 
may be due to the fact that children have been reared in crowded city 
tenements, in institutions, or under other unfavorable surroundings. 
A local predisposition may be afforded .by any pathological condition 
of the organs or mucous membranes exposed to infection. Thus, adenoid 
growths of the pharynx or large tonsils favor the development of tubercu- 
losis of those structures and secondarily of cervical adenitis ; and frequent 
attacks of bronchitis may precede pulmonary tuberculosis. Certain infec- 
tious diseases, particularly measles, whooping-cough, and influenza, in- 
crease a child's susceptibility to tuberculosis, but they chiefly cause a 
latent tuberculosis to develop into an active process. General or pul- 
monary tuberculosis is therefore often seen as a sequel to the diseases 
mentioned, the latent focus for which has been tuberculous bronchial 
glands. 

Modes of Infection. — Intra-uterine infection, although rare, has been 
established by the report of a number of complete and well-authenti- 
cated cases. Tuberculosis of the placenta is more frequent. In most of 
the cases of congenital tuberculosis the mother has been suffering from 
the disease in an advanced form, and the child is either still-born or 
dies soon after birth. Besides tuberculosis of the placenta, tubercle 
bacilli are found in the organs of the child, and, when life is prolonged, 
there are generalized lesions showing infection through the blood. 
Cheesy nodules have been observed in the umbilical cord, [ntra-uterine 
in lection is highly probable in many of the children born of tuberculous 
mothers, who develop the disease during the first few months of life, al- 
though they may show no evidence of it at birth. Among our own cases 
there was one only twenty days old and another six weeks old. The chil- 
dren were born prematurely of mothers suffering from advanced tubercu- 
losis. Besides other lesions, the autopsy showed, in the ease of one 
mother, tuberculosis of the endometrium. 

Tuberculosis may be communicated by direct inoculation, as in the 
case of a bite from a person suffering from the disease, several instances 
of which are on record. The rite of circumcision performed by a rabbi 



1070 THE SPECIFIC INFECTIOUS DISEASES 

suffering from tuberculosis we have known to cause the disease. One 
of the most striking instances of direct infection is that reported by 
Eeich. In a town of about 1,300 inhabitants, the obstetric practice was 
divided between two midwives. Within fourteen months no less than 
ten infants, who had been delivered by one of these women, died of 
tuberculous meningitis. In none of these families was there a history 
of tuberculosis. This midwife was found to be suffering from pulmonary 
tuberculosis, and died from that disease. It was her custom to remove 
the mucus from the mouth of the newly-born infants by direct mouth- 
to-mouth aspiration, and then to establish respiration by blowing into 
the nose. In the practice of the othei midwife, who was healthy, no 
cases of tuberculosis occurred, although she treated the newly-born in- 
fants in the same fashion. 

Altogether the most frequent means by which young children ac- 
quire tuberculosis is from association with persons suffering from pul- 
monary tuberculosis. Some of these are persons in the active stage of 
the disease; many are supposed to have been cured; in others the disease 
has not yet developed so as to be recognized. Bacilli may be directly 
conveyed by kissing. Dried sputum containing bacilli may become a 
part of the dust of the room ; it may be inhaled or it may be introduced 
into the mouths of children by hands, toys, or other objects. The source 
of infection is usually one or other parent or some member of the house- 
hold — a nurse, caretaker, servant, or a frequent visitor. A history of 
such exposure was definitely traced in forty-four per cent of 101 con- 
secutive cases of tuberculosis in young children which were investigated 
at the Babies' Hospital. These figures do not represent the proportion 
of the cases in which the disease is so contracted. There is a very much 
larger number in which this connection can not be traced. Doubtless 
exposure antedates symptoms by a number of weeks at least, often by 
several months. In instances where it could be pretty accurately ascer- 
tained, the interval between exposure and development of symptoms was 
from four to twelve weeks. 

Infection may take place from beds, rooms, sleeping cars, or any 
apartments previously occupied by tuberculous patients; from dishes or 
spoons, from glasses at public drinking places; also though very rarely 
from the meat of tuberculous cattle. Our own observations lead us to the 
conclusion that only a very small proportion of children contract tuber- 
culosis in these indirect ways. Infection through milk is, however, of 
not infrequent occurrence. (See Chapter II, page 134, The Infant's 
Dietary.) It has been repeatedly shown that a considerable per- 
centage of the milk offered for sale in cities contains tnbercle 
bacilli. In almost all instances they are of the bovine type. How- 
ever, they are usually present in small numbers and in most cases 



TUBERCULOSIS 



1071 



doubtless pass through the digestive tract without inducing infection. 1 
Types of Bacilli. — Important information in regard to the source of 
infection is obtained from a study of the type of organism present in the 
different varieties of tuberculosis. 

Park and Krumwiede give the following table of results of 543 cases 
of tuberculosis in children studied. About one-third of these were in- 
vestigated by them personally; the remaining two-thirds were collected 
cases. 



Lesions 



Children Under 5j years 



Human Bovine 



5 to 16 Years. 



Human Bovine 



Pulmonary .•••': 

Adenitis, axillary or inguinal 

Adenitis, cervical 

Abdominal 

Generalized 

Generalized, alimentary origin 

Generalized and meningeal, alimentary origin 

Generalized and meningeal 

Meningeal 

Bones and joints* 

Skin 

Genito-urinary 



35 

2 
15 
10 

74 

17 

5 

76 

28 

27 

2 





1 



24 

14 

i 

15 

10 

1 

4 









14 
4 

36 
8 
5 
3 
1 

10 
3 

41 
4 
2 





22 
9 
1 
4 



3 
6 




291 



76 



131 



45 



* Frazer states that "of a series of cases of bone and joint tuberculosis studied in Edinburgh 62 
per cent were bovine in their origin." Apparently the incidence of bovine infection varies consider- 
ably in different countries. The inference is that the milk supply of Scotland is more likely to be 
infected than that of other places. 

These figures indicate that nearly all pulmonary and meningeal tu- 
berculosis as well as tuberculosis of bones and joints is human in origin, 



1 In this connection the following incident is interesting as bearing upon 
the other side of the question: Near a large American city was a fancy stock 
farm of registered Jersey cows, which supplied milk for table use and infant 
feeding to a large number of families in the wealthiest part of the city, for a 
period of over ten years. At the end of that time the tuberculin test was used 
for the first time, and 45 per cent of these cows were found to be tuberculous, 
and were killed by order of the State Board of Health. The diagnosis was con- 
firmed by autopsies upon the animals in every instance. An investigation was 
instituted among the children who had been fed upon this milk, but in only one 
case of many hundreds could it be learned that tuberculosis had developed, 
and in this instance it was by no means established that the milk had been the 
source of infection. It should be stated that this was before the days of steriliz- 
ing milk for infant feeding. Besides the families who took the milk in the 
manner mentioned, the employees at the farm wen 1 accustomed to drink the 
skimmed milk in large quantities daily as a beverage in the place of water. 
Many of them continued to do lliis for years, and yet not one of them developed 
tuberculosis. 



1072 THE SPECIFIC INFECTIOUS DISEASES 

but that on the other hand, tuberculosis affecting chiefly the abdomen or 
springing from the alimentary tract, and tuberculosis of the cervical 
glands is frequently bovine in origin. 

Infection from the meat of tuberculous animals is a . possibility, 
but hardly more. Bollinger's experiments in feeding animals with the 
expressed juice of such meat gave negative results. 

Paths of Infection of the Tubercle Bacillus. — Tubercle bacilli may 
gain entrance to the body through the respiratory or the alimentary 
tract or the skin, the last, however, being so rare that it needs only to be 
mentioned. In infancy and early childhood infection is undoubtedly 
most frequent through the respiratory tract. The situation of the pri- 
mary lesions strongly supports this view. The infection is the result of 
the inhalation of tubercle bacilli, probably in dried sputum, and is there- 
fore nearly always an infection with the human type of the tubercle bacil- 
lus. Infection through the alimentary tract is by way of the tonsils or 
the intestines, and either the human or bovine type of organism may be 
introduced into the body in this way. If it is the human type, in all 
probability the patient himself is suffering from pulmonary tuberculosis 
and the tonsils or the intestines are infected from the sputum coughed 
up. There is also the possibility of human tubercle bacilli being taken 
into the mouth from contaminated articles or in milk. Bovine infection 
almost always results from drinking milk from tuberculous cows. 

Animal experiments have shown conclusively that bacilli may pass 
through a mucous membrane without inducing either a macroscopical or 
microscopical form of tuberculous disease but that penetration is much 
easier if the mucous membrane is the seat of a catarrhal inflammation 
or if the epithelium has been injured. While it is possible that infection 
of the cervical, mediastinal and tracheobronchial glands may take place 
without a lesion of the mucous membrane which these lymph nodes drain, 
recent studies have shown that it is very uncommon. Thus, with tuber- 
culosis of the cervical glands, pathological examination of the tonsils 
and inoculation experiments show that the tonsils are usually the seat 
of tuberculous disease. The same is true of the mesenteric glands. To 
superficial examination, the mucous membrane of the intestinal tract 
may appear normal ; but careful examination of it has in our experience 
almost always resulted in the discovery of one or more tuberculous lesions. 
Such is the case also with the lungs, as shown by Parrot, Hervouet, Kiiss, 
H. Albrecht and Ghon. The tubercle bacilli which pass the upper respira- 
tory tract may not be arrested until the smaller bronchi are reached. 
In one of these they set up a localized tuberculous process which may 
remain very small, but frequently reaches the size of a pea. This area 
undergoes the ordinary changes induced by the tubercle bacilli and event- 
ually necrosis or perhaps calcification occurs. The tuberculous focus 



TUBERCULOSIS 1073 

is frequently surrounded by fairly firm fibrous tissue. From this original 
pulmonary focus, infection of the tracheobronchial glands takes place by 
way of the lymphatics. The focus may remain small and apparently 
innocuous. Further development of the tuberculosis may take place 
from the tracheobronchial glands, either in the form of a diffuse inflam- 
mation spreading into the parenchyma of the lung along the lymphatics, 
or from the softening and rupture of the gland either into a bronchus 
or into a vein. The original tuberculous lesion in the lung on account 
of its small size may be overlooked, but careful examination will usually 
disclose it. In a series of 169 autopsies at the Babies' Hospital upon 
children (mostly infants) with tuberculous bronchial glands, Bartlett 
and AVollstein found pulmonary lesions in 158 cases, or 93.5 per cent. 
Ghon found, in 184 autopsies upon children with tuberculous bronchial 
glands, a primary pulmonary focus in 170, or- 92.4 per cent. It was 
his opinion that more careful examination would probably have revealed 
the focus in others. The changes in the tuberculous tracheobronchial 
glands are those of ordinary tuberculosis elsewhere — congestion, swelling, 
cell proliferation and caseation or the process may be arrested at any 
point and the products of inflammation become encapsulated by the pro- 
liferation of fibrous tissue in which condition they may remain latent in 
the body for an indefinite number of years, possibly for a lifetime. This 
occurs in many children and is consistent with every outward sign of 
health, but it is a smouldering ember which at any time may be fanned 
into flame under the stimulus of an inflammation excited by some other 
cause. 

Lesions. — In the table (p. 1071) are given the lesions found in 255 
autopsies, of which we have notes. These represent the lesions of infancy 
and early childhood, seventy per cent of these children being two years 
old or under. For comparison there are given statistics of 131 autopsies 
from the Pendlebury Hospital, Manchester, England. Few of the chil- 
dren in this series were under three years old. The greater frequency 
of abdominal tuberculosis, especially tuberculous peritonitis, will be 
noted. This difference obtains in nearly all the English statistics of the 
disease. 

The Varieties of Tuberculosis seen at Different Ages. — During the 
first two years of life, tuberculosis most frequently invokes flic lungs 
and bronchial lymph nodes. It is the meningeal or pulmonary process 
which most often is the cause of death. Death from other forms of 
tuberculosis is rare at this time of life. Of 232 deaths from tuberculosis 
in the first three years of life, meningitis was the cause in 93, tuberculous 
peritonitis in only one, and hemorrhage from a tuberculous ulcer of the 
intestine in one. 

After the second year, tuberculosis of the boneflj cervical and tnesen- 



1074 



THE SPECIFIC INFECTIOUS DISEASES 



Frequency of the Different Visceral Lesions of Tuberculosis 



Organs. 



Personal Cases; 1 

255 autopsies (chiefly under 

three years) . 



Pendlebury Hospital Reports; 

131 autopsies (chiefly over 

three years). 



Lungs 

Pleura 

Bronchial lymph nodes. 

Brain 

Liver 

Spleen 

Kidneys 

Stomach 

Intestines 

Mesenteric lymph nodes 

Peritoneum 

Pericardium 

Endocardium 

Thymus 

Suprarenal capsules 

Pancreas 



235 
93 

208 

85 

178 

191 

88 

7 

110 

118 

22 

10 

1 

5 

4 

4 



92 . 1 per cent 

36.5 

81.5 

33.3 

69.8 

74.9 

30.6 

2.7 
43.1 
46.2 

8.6 

3.9 

0.4 

1.9 

1.5 

1.5 



122 

100 

91 

60 

86" 

76 

54 

1 

65 

77 

37 

4 



93 . per cent 

76.0 

70.0 " 

46.0 

65.0 

58.0 

41.0 

0.8 " 
50.0 

59.0 " 
28.0 

3.0 " 



1 . 6 per cent 



1 In a second series of 178 autopsies at the Babies' Hospital the lungs were 
involved in 92.1 per cent.; the bronchial lymph nodes in 95.5 per cent.; the brain 
in 38.7 per cent., and the mesenteric lymph nodes in 63.5 per cent. 

teric lymph nodes, peritoneum, and intestines becomes more frequent, 
and any of them may occur as the principal lesion, although at autopsy 
the lungs are usually involved to some degree. 

Pulmonary Lesions. — As compared with that of adults, the pulmo- 
nary tuberculosis of young children is more widely diffused, and the pre- 
dominance of cases in which the lesion is in the upper lobes is less 
marked, though it still exists. In those who have passed the sixth or 
seventh year, the pathological processes resemble those of adult life. Al- 
though localized tuberculous processes are frequently met with in patients 
dying from other diseases, those who die from tuberculosis usually show 
wide-spread lesions of the lungs. 

1. Miliary Tuberculosis of the Lungs. — In nearly every case of pul- 
monary tuberculosis, miliary tubercles are found in some part of the lung, 
usually upon the surface and in the vicinity of some older process. Occa- 
sionally, they are distributed throughout nearly the whole of both lungs. 
In some places the lung, with the exception of these numerous gray 
granulations, appears quite normal; in others it is congested, and shows 
between the tubercles the lesions of simple bronchopneumonia in its 
various stages. There is also an acute bronchitis of the middle-sized 
and smaller bronchi. The microscope shows that the tubercles usually 
develop in the walls of the small bronchi or the blood-vessels. In their 
gross appearance, the lungs in these cases resemble those in ordinary 
acute bronchopneumonia, with the exception that everywhere upon the 



TUBERCULOSIS 1075 

surface and throughout the substance of the lung are seen the small 
gray granulations, and in most cases some small yellow tuberculous 
nodules. The pleura is usually normal except for the presence of the 
tubercles. This form of the disease represents the rapid dissemination 
of tubercle bacilli throughout the lungs, the miliary tubercles being the 
result of the inflammation excited by their presence. 

2. Tuberculous Bronchopneumonia. — This is the most frequent and 
the most characteristic form of tuberculosis in infants and young chil- 
dren, and it is the one which at this age usually causes death. In this 
form of the disease there are produced in the lung caseous nodules, or 
larger caseous areas, some of which have usually undergone softening by 
the time the case comes to autopsy. The process generally runs a some- 
what subacute course. With the lesions mentioned there are always asso- 
ciated those of simple bronchopneumonia. 

The pleura is involved in almost every case. There may be simply 
dense connective tissue adhesions which bind the lung firmly to the chest 
wall, the diaphragm, and the pericardium, or the pleura may be greatly 
thickened and contain caseous deposits. Occasionally empyema is seen, 
but it is almost always sacculated and small. 

Both lungs are usually involved, but one to a much greater degree 
than the other. There are found large areas of consolidation which some- 
times involve an entire lobe, but more often smaller areas are seen in 
several lobes. These portions of the lung appear much firmer and harder 
than in ordinary pneumonia. The upper lobes are more often affected 
than the lower, and especially that part of the lobe which is near the root 
of the lung, on account of its frequent association with tuberculosis of 
the bronchial glands; the disease very often extends forward from this 
point to the middle lobe of the right, or the corresponding part of the 
left lung. On section the affected part of the lung usually shows many 
caseous nodules, varying in size from a pin's head to a walnut, which 
are of a pale-yellow color, and resemble caseous lymph nodes. They 
contain giant cells and are usually filled with bacilli, those which have 
softened containing yellow pus. There is nearly always seen in some 
part of the lung a large caseous area; and not infrequently there may 
be diffuse caseation of almost an entire lobe (Figs. 174, 175). Some- 
times no spot of softening is seen even in these large areas, but in many 
cavities are present. 

Softening and excavation represent the final stages of the process 
in tuberculous pneumonia. Softening usually begins in the center of a 
caseous part, often at several points at the same time. Areas of excava- 
tion large enough to deserve the name of cavities were prescnl in about 
half of our autopsies upon tuberculous patients, two years old and under. 
They vary in size from a cherry to a hen's egg, and sontetinies a much 



1076 



THE SPECIFIC INFECTIOUS DISEASES 



larger one is seen (Fig. 174). They are usually rather deeply seated, 
and are partially or entirely filled with caseous masses or pus, but very 
seldom perforate the pleura, causing pneumothorax or pyopneumothorax. 
It is rare in a young child to find cavities surrounded by dense fibrous 
walls such as are seen in older children or in adults; for in infancy the 




Fig. 173. — Tuberculous Pneumonia. A 
vertical section through the middle of the 
right lung of a child thirteen months old. 
The greater part of the upper lobe is uni- 
formly caseous — a diffuse tuberculous 
pneumonia; near the center the com- 
mencement of a cavity is seen; below it 
has the appearance of a consolidation 
from simple pneumonia. The part of the 
lower lobe shown is normal. 




Fig. 174. — Cavity from Breaking Down 
of Tuberculous Pneumonia. Another 
view of the same lung, the section being 
made very near the posterior border of 
the lung. The cavity occupies at this 
point nearly the whole of the upper lobe. 
At autopsy this cavity contained numer- 
ous loose caseous masses, the largest be- 
ing the size of a marble. The lower lobe 
is normal. (For history, see Fig. 179.) 



process of softening once begun usually advances steadily until the death 
of the patient. 

The bronchial lymph nodes are in these cases invariably found to be 
tuberculous, and not only those at the root of the lung, but if a dissection 
is made, a chain of these tuberculous glands will be found to follow the 
larger bronchi for some distance into the lung (Fig. 175). Sometimes 



TUBERCULOSIS 



1077 



one may be discovered which has softened and ulcerated through into a 
small bronchus. 

Microscopical examination of these cheesy nodules shows that they 
most frequently begin as tuberculous deposits in the walls of the small 
bronchi, either in the mucous membrane, the fibrous coat, or the lymphat- 
ics ; sometimes, however, they begin in the walls of a small vein or artery. 




Fig. 175. — Pulmonary Tuberculosis, Extensive Caseation of Left Lung and 
Bronchial Glands. History. — Colored child, 2 l /i years old; signs over left lung 
were feeble breathing and flatness, suggesting empyema; twenty-three examinations 
of the sputum made for bacilli, all negative. For the last three and a half weeks, 
temperature showed a regular daily range from 100° to 104° F. 

Autopsy. — Almost complete caseation of left lung; no spots of softening; through- 
out right lung were small tuberculous nodules and miliary tubercles. Bronchial 
glands very large and caseous, but none broken down; those affected were not only 
the group at the root of the lung but the chain following the main bronchus some 
distance into the lung itself, 



Cell proliferation takes place, separating the coats of the bronchus or 
blood-vessel, and partly or entirely obstructing its lumen. Softening 
may take place and the contents be discharged into the bronchus or blood- 
vessel. About this focus other changes of an inflammatory character 
occur, as a result of which each cheesy nodule is surrounded by a zone 
of simple bronchopneumonia which tends, in a measure at least, to limit, 
the tuberculous process. The larger caseous areas are formed by an 



1078 THE SPECIFIC INFECTIOUS DISEASES 

extension of this process to the zone of pneumonia which surrounds it; 
but in its further growth it is still preceded by a simple pneumonia. 
The rapidity with which the lesions advance differs much in the different 
cases; in infants the progress is apt to be continuous until the death of 
the patient; in older children it is usually slower, and interrupted by. 
intervals of arrest and even of partial retrogression. 

Not infrequently one sees in the post-mortem room one or two caseous, 
or less frequently calcareous, nodules encapsulated by firm, organized con- 
nective tissue when a most careful search fails to show any other tuber- 
culous lesion in the lung. If, however, the nodules are widely scattered 
through the lung, such an arrest of the process is not to be expected. 

3. Chronic Pulmonary Tuberculosis, Chronic Phthisis. — - In children 
who have passed the seventh or eighth year the pathological process re- 
sembles that seen in adults; but in younger children, and especially in 
inf cants, nothing corresponding to it is met with. 

At this period the nearest approach to this condition is seen in the 
cases of tuberculous bronchopneumonia, which run a slow, irregular, 
and somewhat chronic course. The essential features of the process in 
these patients is a chronic interstitial bronchopneumonia with tuber- 
culous nodules which rarely undergo softening, but usually become en- 
capsulated. 

The gross lesions closely resemble those of simple chronic broncho- 
pneumonia. There are the same generalized pleuritic adhesions and the 
shrunken cicatricial condition of the part of the lung most affected, with 
bronchiectasis, compensatory emphysema, etc. The tuberculous nodules 
are old and for the most part converted into dense fibrous tissue, in the 
center of which, however, some softened, caseous areas are often seen. 

Bronchial Lymph Nodes (bronchial glands). — The prominence of the 
lesions of the lymph nodes is one of the most striking features of tuber- 
culosis in infancy and early childhood. Those which are most frequently 
affected are connected with the bronchi. The lymph nodes, to which the 
term "bronchial glands" is generally applied, consist of three groups: 
the first of which surrounds the trachea; the second is situated at the 
bifurcation of the trachea and surr#unds the primarj bronchi ; while the 
third follows the course of the bronchi into the lung, being found, ac- 
cording to anatomists, as far as the fourth division. The anatomical 
relations of the different groups should be borne in mind, since upon them 
the symptoms principally depend. The first group, or the peritracheal 
lymph nodes, are in relation with the superior vena cava, the pulmonary 
artery, the pneumogastric and recurrent laryngeal nerves; the second 
group, at the bifurcation of the trachea, with the esophagus, pneumo- 
gastric nerve, and aorta; the third group, with the bronchi and the 
branches of the bronchial and pulmonary arteries and veins. 



PLATE XIII 




Tuberculosis of the Tracheobronchial Lymph Nodes 
From a fairly nourished child, four months old, who was under observation for 
three weeks, with slight fever and a most severe, teasing, dry cough, which was almost 
constant, and upon which no treatment seemed to have the slightest effect. At first 
there were no signs of disease in the lungs; later there were a few coarse scattered rales. 
There were small tuberculous deposits throughout both lungs, with quite a large 
area of cheesy pneumonia in the right middle lobe, and scattered miliary tubercles in 
other organs. 



TUBERCULOSIS 1079 

All the groups are usually involved at the same time, but in varying 
degrees, and in most cases those belonging to one lung to a greater extent 
than the other; in our own cases those of the right side have much more 
often been involved than those of the left. There may be simply two 
or three tumors as large as a hazelnut, or there may be a mass two 
or three inches in diameter, which is made up of ten to twenty of these 
nodes fused together by inflammatory products, completely surrounding 
the trachea and both the large bronchi. It is rare that the individual 
glands are more than an inch in diameter, and most of them are smaller 
than this. A well-marked but not unusual example of this condition is 
shown in Plate XIII. There is usually found a chain of these tuber- 
culous glands following the course of the large bronchi for some distance 
into the lung; sometimes these are almost as large as the external group 
(Fig. 175) ; at other times they are not noticed unless a somewhat care- 
ful dissection is made. The process is not infrequently more advanced 
in these deeply seated glands than in those situated at the root of the 
lung; and lesions here are also more important, as it is very frequently 
from them that an extension of the process takes place. 

The pathological changes through which these glands pass as a re- 
sult of tuberculous infection are very similar to those already described 
with reference to the cervical glands. Suppuration is less frequent than 
in the region of the neck, while calcific degeneration is much more so. 
This applies especially to children over three years old. In infancy 
suppuration is not infrequent in the bronchial glands, while at this age 
calcification is relatively rare. Although the process has gone on to 
caseation, these inflammatory products with bacilli may become encapsu- 
lated, and may remain innocuous for an indefinite period. The bacilli 
may die or may exist here, living, for years. At any time the old process 
may be lighted up, and a more or less rapid dissemination of tubercle 
bacilli take place through the lungs or through the whole body. Latent 
tuberculosis more frequently exists in the bronchial lymph nodes than 
in any other structure in the body. 

Secondary lesions may be produced by these lymph nodes. The pneu- 
mogastric and recurrent laryngeal nerves may be surrounded by one of 
these cheesy masses which may cause pressure or irritation. The esoph- 
agus, the trachea, or the bronchi may be compressed or opened by ulcera- 
tion. The superior vena cava usually suffers only compression, but this or 
any of the other large vessels may be opened. Ulceration may also take 
place into one of the large or small bronchi or the trachea. I f the gland 
has softened and broken down, and it' the bronchus is a small one. the only 
result of this may be a rapid spreading of tuberculous infection through- 
out the lung. If sudden rapture occurs, a large caseous mass may escape 
into the trachea, or a large bronchus, with a result similar to that pro- 



1080 THE SPECIFIC INFECTIOUS DISEASES 

duced by any other foreign body. If suppuration occurs, the abscess 
may rupture into the surrounding cellular tissue, causing mediastinal or 
retro-esophageal abscess. This may open externally at the suprasternal 
notch, or in the first or second intercostal space, or may ulcerate into any 
of the large vessels, the esophagus, or the pericardium. 

Pleura.— This is rarely normal in any case of tuberculosis. In acute 
general tuberculosis the only lesion may be a deposit of miliary tubercles 
upon the visceral pleura. In most of the other cases there are found 
fibrous adhesions over the part of the lung involved, binding it to the 
pericardium, the diaphragm, or the chest wall. The amount of thicken- 
ing of the pleura varies a good deal, but is rarely great. Pleurisy with 
a serous effusion is not common in infants or young children; when it 
occurs it is apt to be sacculated. Hemorrhagic exudation is very rare 
at this age. Empyema is also rare, being seen in but five per cent of 
our cases, and then it has been small and sacculated. Pneumothorax and 
pyopneumothorax are very rare in children under three years of age. 

Heart. — It is exceptional for the pericardium to be affected even in 
the most generalized forms of acute miliary tuberculosis. In such cases 
the usual lesion is a deposit of a few gray tubercles upon the visceral 
surface. In chronic cases other lesions analogous to those of the pleura 
may be seen, but very infrequently in childhood. Usually only localized 
adhesions are present, but we have seen complete obliteration of the peri- 
cardial sac from tuberculous inflammation in an infant of eleven months. 

In several instances we have seen miliary tubercles and minute cheesy 
nodules upon the mural endocardium, most frequently in the conus ar- 
teriosus of the right ventricle. One case, an infant sixteen months old, 
had such lesions in both ventricles and in addition miliary tubercles upon 
the tricuspid valve. 

Brain. — Tuberculosis of the brain is very common during infancy, 
being then associated in nearly all cases with general tuberculosis. Mili- 
ary tubercles are occasionally found in small numbers in cases which have 
presented no symptoms. The lesions of tuberculous meningitis have al- 
ready been described. Cheesy nodules are rare in infancy, being noted 
in but 2.5 per cent of our own autopsies, which were mainly on children 
under three years old; while in the Pendlebury Hospital cases, including 
those between four and twelve years old, they were noted in 24.4 per cent. 
These nodules vary in size from a pea to a hen's egg; they are usually 
associated with tuberculous meningitis, but they may exist alone. When 
they are large they rank as cerebral tumors, being most frequently seen 
in the cerebellum. 

Liver. — This is frequently involved in general tuberculosis, although 
it is doubtful if it is ever the seat of primary infection except in the con- 
genital cases. Usually the only lesion is the presence of miliary tubercles 



TUBERCULOSIS 1081 

on its surface and in its substance, and in most cases these are not nu- 
merous. They are found in about two-thirds of the cases. In a smaller 
number there are tuberculous nodules of various sizes, especially about 
the biliary ducts. In nearly every protracted case the liver is markedly 
fatty. In very late cases of tuberculosis of the bones, it is frequently the 
seat of amyloid degeneration. 

Spleen. — This is more frequently affected than the liver, but the 
lesions are similar. The size of the spleen is not much increased if only 
miliary tubercles are present; but with tuberculous nodules it may be 
greatly enlarged. Amyloid degeneration is found under the same condi- 
tions as in the liver. 

Stomach. — Tuberculosis of the stomach is one of the rare lesions; 
both its contents and its acid reaction seem to protect it against direct 
infection from the mouth. Tuberculous ulcers were seen in five of our 
autopsies, which is a larger proportion than is usually noted. 

Intest ines.— That these are less seriously affected in infants than In 
older children is rather surprising when we consider how susceptible are 
the intestines of infants to other forms of infection. The explanation 
of this difference seems to be that in infancy intestinal infection is usually 
secondary to disease of the lungs, primary lesions being relatively rare. 
Infants die from the more rapid tuberculous processes in the lungs or 
brain before there has been time or opportunity for secondary intestinal 
lesions of importance to occur. The intestinal lesions and those of the 
mesenteric lymph nodes with which they are almost invariably associated, 
arc described elsewhere. 

Peritoneum. — In early infancy the peritoneum is not often involved 
even in general tuberculosis, and at this age it is very rare for it to be the 
scat of the principal tuberculous process. In older children it is more 
frequent. In most cases of general tuberculosis there are only deposits 
of miliary tubercles; less frequently there are tuberculous nodules with 
other inflammatory products. The lesions in these cases are described 
with Diseases of the Peritoneum. 

Thymus Gland. — In several of our cases tuberculous nodules have 
been found in the thymus gland, the size varying from a small pea to a 
hazelnut. All the cases showed also widely disseminated tuberculous 
lesions. 

Pancreas. — In a very few of our cases this organ also was the seal of 
small tuberculous nodules, all of them being eases of general tuberculosis. 

Urogenital Organs. — Serious tuberculosis of any part of the urinary 
tract is very rare in children. Miliary tubercles have been found in the 
kidneys in about one-thinl of our autopsies on t uberculous patients. They 
are generally few in number. Large tuberculous nodules of the kidney 
are very rare before the fourteenth year, Tuberculous nodules are rarely 



1082 THE SPECIFIC INFECTIOUS DISEASES 

found in the suprarenal capsules. Tuberculosis of the testicle is very 
rare in children. We have seen but a single instance of it. This was in 
an eight months old child. We have records of two cases of tuberculosis 
of the prepuce and inguinal glands following ritual circumcision, in both 
cases followed by generalized infection. 

Tuberculosis of the bones and of the external lymph nodes has already 
been described. 

THE CLINICAL FORMS OF TUBERCULOSIS 

I. General Tuberculosis. — Cases of tuberculosis present a wide 
variety in their symptomatology, depending upon the seat of infection, 
the rapidity with which the bacilli are disseminated through the body, or 
the numbers in which they enter. The general symptoms often precede 
the local ones, but are not recognized as those of tuberculosis. Often it 
is Dot suspected until the process is quite well advanced in some one 
organ. 

In Infants. — The early symptoms in infancy are often only those of 
failing nutrition. The patients are pale, thin, do not gain in weight 
no matter how fed, and finally lose steadily without sufficient reason. 
There may be no cough or fever sufficient to attract attention, and the 
case may even go on to a fatal termination without anything else than 
simple marasmus having been suspected, tuberculosis being first recog- 
nized at the autopsy. 

More frequently, however, there are developed toward the end of the 
illness both the symptoms and signs of pulmonary disease and fever. 
These are generally found together, as the process in the lungs is usually 
the cause of the rise of temperature. The febrile symptoms are often 
not seen until the last few weeks of life. The course of the temperature 
is irregular. It is never of the hectic type and rarely high. The usual 
range is between 100° and 102° F. The pulmonary symptoms are gen- 
erally few and not very well marked. There is some cough, but it is 
rarely severe. The breathing is more rapid than would be explained b} r 
the temperature alone. Severe dyspnea and cyanosis are rare, and are 
seen only at the close of the disease. The physical signs are those of 
either localized or general bronchitis. Digestive symptoms are usually 
present late in the disease, but diarrhea is rarely due to a tuberculous 
lesion of the intestines. 

The progress of the case after constitutional symptoms develop is 
usually steadily downward, and the child lives but a few weeks at most. 
Death generally occurs from progressive asthenia without the develop- 
ment of any new symptoms, or cerebral symptoms rapidly develop and 
the child is carried off in a few days by tuberculous meningitis. Some- 



TUBERCULOSIS 1083 

times there is a rapid spreading of the disease in the lungs, and death 
occurs with symptoms of acute pneumonia. 

General tuberculosis in infants is to be differentiated from marasmus 
with bronchitis; rarely it may be confounded with hereditary syphilis. 

In Older Children. — The development of active general tubercu- 
losis in older children is usually preceded by a protracted period of 
indefinite symptoms. They are persistently anemic without evident rea- 
son; they lose weight; digestion is disturbed; the appetite is capri- 
cious; they sleep badly; they are irritable, fretful, and easily fatigued. 
These symptoms indicate only a gradual decline in general health, and 
may readily be explained by many other causes than tuberculosis. They 
should, however, excite a suspicion of tuberculosis in a child who by 
surroundings or inheritance is predisposed to that disease. 

After these indefinite symptoms have lasted for a few weeks fever is 
added. Sometimes the prodromal symptoms are absent or unnoticed, 
and fever is the first evident symptom. From the beginning of fever 
some cases progress rapidly to a fatal termination in three or four weeks. 
In the majority, however, the disease runs a slower course. The fever 
often exists without evident cause and without any local manifestations 
of disease. The temperature is not often high, but it is continuous. The 
tympanites and the rose-colored spots are not present, but the general 
aspect of the patient is strikingly suggestive of typhoid fever. But the 
course of the temperature and the duration of the illness show that we 
have to deal with some other condition. 

After the fever has lasted from one to three weeks there develop some 
signs of localized tuberculosis, generally in the lungs, or the fever may 
decline gradually, and although the patient improves he does not get 
well. He is still weak and does not gain in weight, and the thermometer 
shows the existence of a very slight amount of fever. Before long he 
may grow rapidly worse and the course of the temperature becomes ir- 
regular, Avith alternate exacerbations and remissions. Such an irregular 
and inexplicable fever sometimes puzzles the physician for several weeks 
before the characteristic features which stamp the process as tuberculous 
are present. Before very long wasting is added to the fever. This may 
not be rapid, but is progressive. The tuberculous cachexia is frequently 
unmistakable; but in most of the cases one must wait for the process 
to advance far enough in some one of the organs to give local eigne or 
symptoms before he can be sure of tuberculosis. In four cases out of five 
this is in the lungs, and frequently repeated examinations of (he sputum 
may reveal the bacilli. Less often it is in the peritoneum, the brain, 
or a general infection of the lymph glands throughout the body. If in 
the lungs, the process manifests itself as a bronchopneumonia whose 
tuberculous character may sometime^ he suspected from its location — the 



1084 THE SPECIFIC INFECTIOUS DISEASES 

apex or the middle of the lung in front — but chiefly from the fact that 
the general symptoms, fever and wasting, have so long preceded the local 
signs. From this time, the course may be that of a typical tuberculous 
bronchopneumonia. 

If the tuberculous process is localized in the brain, there may be vom- 
iting, headache, drowsiness, irregular pulse, irregular respiration, and 
finally convulsions and coma: — in short, the symptoms of tuberculous 
meningitis; if in the peritoneum, there are abdominal distention from 
gas or fluid, tenderness, pain, diarrhea, or constipation ; if in the lymph 
glands, there is a general enlargement of those situated externally, some- 
times with symptoms indicating similar changes in those at the root of 
the lung. 

II. Pulmonary Tuberculosis. — Tuberculosis of the lungs in children 
may be seen in a variety of clinical forms which correspond with the 
different pathological conditions. The pathological conditions are often 
associated, yet the main clinical types are sufficiently distinct to give 
quite a definite picture. These types are: (1) miliary tuberculosis of 
the lungs; (2) bronchitis with small, scattered, tuberculous nodules; (3) 
tuberculous bronchopneumonia with areas of consolidation, often ex- 
tensive, which may be followed by caseation and excavation, or by chronic 
fibrous induration. 

Miliary Tuberculosis of the Lungs. — This is not a common form 
of pulmonary tuberculosis, but may be met with even in young infants. 
Both the general and pulmonary symptoms and the physical signs are 
rather obscure and indefinite, and often the diagnosis is not made. Oc- 
casionally the only symptoms are those of marasmus, neither fever nor 
physical signs in the chest being present (Fig. 176). As we have seen 
it in young children, it has seldom been attended by high temperature, 
101° to 103° F. being the usual range. Throughout the greater part of 
the disease it is often lower than this, and toward the close perhaps rather 
higher. It is not a hectic type of fever, and it seldom touches the normal 
line. 

The duration of the disease in these cases, after fairly definite symp- 
toms begin, varies from ten days to a month. At first, and often for 
two or three weeks, the temperature is almost the only symptom. Cough 
is slight, inconstant, and seldom loose. There is no sputum. The respi- 
rations are only moderately accelerated, in many cases not enough to 
draw attention to the lungs as the seat of disease. There is no rapid 
wasting, the loss in weight being usually not more than would be ex- 
pected with any other febrile disease. None of the other symptoms sug- 
gests tuberculosis. The usual problem in diagnosis is to discover the 
cause of the fever. Often the most careful examinations of the chest 
made daily reveal nothing more than a few scattered rales. These change 



TUBERCULOSIS 



108: 



in position from time to time, and it frequently happens that for days 
no rales are heard. After the disease has progressed somewhat further, 
the liver and spleen are generally enlarged. Cerebral symptoms may de- 
velop, and the case terminate as tuberculous meningitis, but more often 
it is the pulmonary symptoms which are dominant. The respirations 
become more rapid; the cough is frequent, but rarely loose; there may 
be attacks of cyanosis. Still the only definite signs are the rales, now 
fine and moist, and diffused generally over the chest. The case usually 




Fig. 170. — Miliary Tuberculosis of the Lungs. Infant fourteen months old; symp- 
toms of marasmus; no elevation of temperature; tuberculides of the skin; positive 
von Pirquet reaction; no pulmonary signs or symptoms. The radiograph shows 
great numbers of small tuberculous deposits scattered through both lungs. 



ends iii death by exhaustion, but without rapid or marked wasting. One 
of the most striking things in the clinical picture is the disproportion 
between the severity of the general and pulmonary symptoms and the 
few physical signs in the chest. 

TrisKKCULOUs Bronchitis. — This is not an infrequent condition 
even in infancy. Tn many, perhaps in most, cases it marks the earliest 
clinical stage of a tuberculous bronchopneumonia, but this is not always 
true. The condition seems, therefore, of suHicicni importance to require 
separate consideration. Besides bronchitis, there arc found ai autopsy a 
few small tuberculous nodules and tuberculosis of the bronchial glands, 
although these may give neither signs nor symptoms during life. The 
36 



10S6 THE SPECIFIC INFECTIOUS DISEASES 

symptoms of this condition are few and not distinctive, and may differ 
in no respect from bronchitis due to other causes. Tuberculosis may not 
even be suspected until the lesion has so far developed as to be classed 
as tuberculous bronchopneumonia. Cough is present, but has nothing 
characteristic about it except its persistence. Fever may be absent for 
a long time, but comes as the disease advances. Then it is low and 
very irregular, the temperature generally varying from 99° to 101.5° F. 
There may be slow but progressive loss in weight, or the infant may 
gain regularly for a number of weeks in spite of the cough. This fact 
often leads to a mistake in diagnosis. The nutrition is influenced much 
more by the condition of the digestive organs than by the tuberculous 
process. Other symptoms generally regarded as belonging to early tu- 
berculosis^ such as pallor, anemia, perspiration, etc., are usually absent. 
The physical signs are few and not characteristic. Scattered rales, some- 
times coarse and sometimes finer, but inconstant, are all the signs that 
are present for a long time, often several weeks. 

Cases like these are recognized as tuberculous only by finding bacilli 
in the sputum or by the tuberculin test. It has been our custom to 
consider as probably tuberculous 'every infant who has been for any 
length of time in contact with a tuberculous parent or other member of 
a household. Eegarding all such infants as suspicious has led us in 
hospital practice to search the sputum carefully for bacilli, with the result 
that we have found them, sometimes in great numbers, in infants whose 
only outward symptom was a moderate cough, and who were admitted to 
the hospital for some other reason. At other times the condition has been 
unexpectedly discovered by making routine tuberculin skin tests. A 
typical reaction having been obtained in a child not hitherto suspected, 
the diagnosis has been subsequently confirmed by finding bacilli in the 
sputum, although the only signs in the chest were a few rales and the 
only outward symptom a moderate cough. How many infants there are 
with such a form of tuberculosis and how long such a condition may con- 
tinue without more definite signs developing, one can only conjecture; 
but the number of such cases is, we are convinced, not small. They form 
a very distinct but important group of tuberculous cases. The regularity 
with which bacilli are present in the sputum indicates what a factor 
they may be in spreading the disease. How many recover and in how 
many the disease goes on to the development of more serious lesions it is 
impossible to say. 

Tuberculous Bronchopneumonia. — This is altogether the most 
frequent form of tuberculosis seen in young children. It may be primary 
in the lungs or it may be secondary to tuberculosis elsewhere, most fre- 
quently in the bronchial glands. It may be preceded by constitutional 
symptoms such as those described under the head of general tuberculosis. 



TUBERCULOSIS 1087 

It may follow single or repeated attacks of what was apparently a simple 
acute bronchitis or bronchopneumonia, whether that occurred as a pri- 
mary disease or was in turn a sequel to one of the infectious diseases, 
especially measles, whooping-cough, or influenza. 

Tuberculous bronchopneumonia, as a rule, begins gradually, and its 
course is less rapid than simple bronchopneumonia, its progress being 
generally marked by weeks. When primary it is often preceded by 
symptoms described as tuberculous bronchitis. When it follows one 
of the infectious diseases, it is usually engrafted upon the original dis- 
ease without any intervening symptoms. The early symptoms are cough, 
rapid respiration, fever, progressive weakness, and anemia. The weight 
may be at first stationary, but soon there is steady loss, which may con- 
tinue until there is marked emaciation. At first the usual range of tem- 
perature is from 100° to 102° F. ; later it is rather higher than this. In 
many of the cases it differs little from the temperature of simple broncho- 
pneumonia. Sometimes the general symptoms are severe and the physical 
signs wide-spread, and yet the range of temperature is not high. To 
be sure, this is occasionally seen in simple bronchopneumonia, but it is 
more frequent in tuberculosis. The cough early in the disease is slight, 
but later becomes severe and often distressing. In infants and young 
children it may be of a paroxysmal character, resembling pertussis. 
Expectoration is not often seen in those under five years old. Bloody 
expectoration is very rare in children. 

The conditions in the lungs which give physical signs are bronchitis 
of the smaller tubes with areas of complete or partial consolidation. In 
character, these signs are identical with those of simple bronchopneu- 
monia. They may be scattered throughout the whole of both lungs; but 
when localized they are more frequently in the upper than in the lower 
lobes, and more frequently in front than behind. Although both lungs 
are involved,, they are usually not affected to the same degree. The 
patient may die before signs of complete consolidation are present ; more 
often there gradually develop areas of consolidation, as shown by bron- 
chial breathing and voice and dulness. In some cases although wide- 
spread lesions are found at autopsy the physical signs during life are 
few and indefinite ; sometimes there may be almost none. (See Fig. 17(1.) 

From the beginning of acute symptoms the progress of the disease is 
steadily downward, death occurring as in simple bronchopneumonia. 
The end is marked by cyanosis, great dyspnea, weak pulse, and extreme 
prostration. In a few cases there develop cerebral symptoms, indicating 
tuberculous disease of the brain. Such symptoms may be the first to 
lead the physician to suspect the process to be a tuberculous one. But 
even this is not conclusive, for one. nntv be dealing with an acute menin- 
gitis due to the pneuinococcus. Lumbar puncture will decide. 



1088 



THE SPECIFIC INFECTIOUS DISEASES 



In the more protracted cases there are found in the lungs caseous 
nodules, with larger areas of caseous pneumonia, and usually some areas, 
of softening. The process is not usually so generalized as in the cases 
just described, but as in them there is always associated a certain amount 
of simple pneumonia. The pathological process may terminate (1) in 
diffuse caseation, or (2) in localized caseation and excavation, or (3) 



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Fig. 177. — Tuberculosis Following Measles. Child sixteen months old, inmate of 
an institution. Chart begins on fifth day of a severe, but uncomplicated attack 
of measles, and shows a natural decline to normal. Fever then returned and con- 
tinued till death, twelve weeks later. Record for the period which is omitted was 
much like that which immediately precedes and follows. Early symptoms not acute, 
only slow wasting, slight cough and fever, with scattered rales throughout chest. 
Signs of consolidation not distinct till eighth week, then present in right upper lobe. 
Toward the end, rapid emaciation, marked pulmonary symptoms, and signs of cavity 
at right apex. Autopsy showed a large cavity, extensive tuberculous deposits 
throughout both lungs and in nearly all abdominal organs. 



in partial resolution and the development of a chronic fibroid pneu- 
monia. In the first two varieties the progress is as a rule steadily down- 
ward to a fatal termination, which takes place in from one to three, 
months. In the third form, which is described later, there is partial 
recovery. 

The mode of onset will depend upon the conditions under which the 
disease develops. When the general symptoms of tuberculosis have pre- 
ceded those in the lungs, the evolution of the latter is gradual, with 
cough, rapid breathing, dyspnea, increased prostration, etc. When the 



TUBERCULOSIS 



1089 



pulmonary symptoms are present from the beginning, they are the same 
as in simple bronchopneumonia, with the exception that they usually 
come on less acutely. The latter is true of cases which are secondary to 
some other form of tuberculosis in the bones, peritoneum, etc. 

When pulmonary tuberculosis follows measles (Fig. ITT) or whoop- 
ing-cough which has been complicated by simple pneumonia, the early 
symptoms may present no unusual features. After two or three weeks 
the temperature gradually falls, and the physical signs improve, but 
neither quite disappears. The cough continues, though its severity some- 
what abates. In the course of a few weeks the child, who has meanwhile 
improved somewhat in his general condition, becomes distinctly worse, 
often without any assignable cause. The temperature rises to 102° or 
103° F. ; the cough increases, and an extension of the disease in the 



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Fig. 178. — Tuberculous Pneumonia; General Tuberculosis. Patient eleven months 
old, and under observation at the time he was taken sick. Chart of entire illness 
is given. Disease began- as an acute pneumonia in lower part of left axilla and spread 
to entire lower lobe. Early signs of consolidation; at end of two wicks, flatness so 
marked that a needle was inserted, fluid being suspected. Vomited frequently, and 
had loose discharges from bowels throughout the illness; abdomen much swollen for 
last two weeks. Autopsy showed cheesy pneumonia of part of the upper and the entire 
left lower lobe, where there were two small cavities. Recent tubercles found through- 
out right lung, and extensive deposits in abdominal organs with peritonitis, and intes- 
tinal ulcers. 



lungs is evident by the physical signs. In other cases the progress of 
the disease after a pneumonia which complicates measles is without an 
intervening period of apparent improvement. It sometimes happens that 
the attack of measles or whooping-cough is not accompanied by any seri- 
ous pulmonary symptoms, and the case goes on to apparenl recovery, ex- 
cept that there remain anemia, a slight cough, and fever. The tempera- 
ture, although not high, persists; but it may be two or three weeks before 
there are present definite symptoms and signs of disease in the Lungs. 

Fever is a constant accompaniment of all active tuberculous proi 
in the lungs in the child as in the adult, it being absenl only during the 
periods of remission which occur in the cases of slow ami irregular prog- 
ress. It is a very important guide to the progress of the disease. The 
early fever may depend in part upon coexisting bronchopneumonia, and 
its course may resemble thai of simple pneumonia of the protracted 
variety. There is no typical curve. The fever is not often steadily high, 



1000 



THE SPECIFIC INFECTIOUS DISEASES 



and in many cases it is never so (Fig. 178). It frequently runs for 
several days between 99° and 102° F., and then, without evident cause, 
rises to 104° F. or over. In infants the morning temperature is fre- 
quently subnormal, although the evening temperature may be 102° or 
103° F. Even toward the close of the disease, when softening and break- 
ing down are actively going on, the regular hectic temperature of adults 
is rarely seen in a young child (Fig. 179). While the presence of fever 
is of great significance, its course has almost no diagnostic importance* 
in early life. Especially should one beware of drawing the conclusion 
tli at, because the type of fever is not hectic, there is no breaking down 
of the lung. 

Sweating belongs only to the late stage of the disease, and is usually 



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Fig. 179. — Tuberculous Pneumonia with Extensive Softening and Excavation. 
A delicate child, thirteen months old; weight, 10 pounds; came under observation 
four weeks before death, with consolidation at apex of right lung. Signs increased 
in intensity, and extended in area until there were heard, from clavicle to below the 
nipple, exaggerated bronchial voice and breathing and many moist rales; percussion 
note was flat; behind, the same signs at extreme apex. No distinct signs of a cavity; 
no hectic fever; no sweating. Autopsy showed large cavity (Fig. 173) at rijht apex 
partly filled with caseous masses; diffuse caseous pneumonia (Fig. 174) of the rest 
of right upper lobe, with scattered deposits in the other lobes, the opposite lung, and 
a few in the abdominal organs. 



associated with the hectic type of fever ; both these are regular symptoms 
in children over seven years old, but not in very young children. 

Wasting, like fever, is characteristic of most active tuberculous 
processes. When fever and wasting are associated, tuberculosis should be 
suspected, no matter how obscure the other symptoms may be. The 
wasting is not always rapid, but it is usually continuous. In infants and 
very young children exceptions to this rule are not infrequent, the prog- 
ress in weight depending more upon the feeding and condition of the 
digestive organs than upon the tuberculous process. In the early stage 
of the disease, wasting is especially suggestive when it continues without 
apparent cause after measles or pertussis, or when it persists under other 
circumstances in spite of a good appetite and apparently good digestion. 
It may at first be so slight as not to be noticed unless the scales are em- 
ployed. Tn obscure cases this steady loss of weight is a point of much 



TUBERCULOSIS 10!) 1 

diagnostic value, and is frequently overlooked. Toward the close of the 
disease there is rapid and frequently extreme emaciation. 

Cough is almost invariably present; it may be hard, dry, or sup- 
pressed; it sometimes occurs in paroxysms resembling pertussis, which 
may or may not depend upon the presence of enlarged bronchial glands. 

Expectoration is absent in infants, the material coughed up being 
swallowed. In children over seven years old there often is a profuse 
muco-purulent expectoration, but it is very exceptional below this age. 

Hemoptysis is a rare symptom, but not unknown even in young 
children. Henoch has reported a case of fatal hemoptysis in a child ten 
months old, where the hemorrhage was due to the rupture of an aneu- 
rism in the wall of a cavity. Herz, in 247 clinical cases of tuberculosis 
in children, records 8 of hemoptysis — 4 of them in children under five 
years, and the youngest only eighteen months old. The records of 131 
autopsies on tuberculous children in the Pendlebury Hospital show that 
hemoptysis was four times a cause of death; two of these patients were 
under five years, and one was only twelve months old. We have never 
met with a case of hemoptysis in a child under five years old. 

The respiration is accelerated, and usually out of proportion to the 
rise in temperature. As the lung becomes more and more extensively 
invaded there is constant dyspnea. The pulse is rapid in the early stage, 
and continues so throughout the disease ; toward the end it becomes weak 
and irregular. 

Pleuritic pains in the chest are not frequent in children. Gastro- 
intestinal symptoms, such as indigestion, vomiting, diarrhea, etc., are 
generally present, but are not peculiar to this disease. They usually 
depend upon the patient's general condition, only exceptionally upon 
tuberculous disease of the stomach or intestines. The characteristic 
symptoms of intestinal tuberculosis — abdominal pain, tenderness, uncon- 
trollable diarrhea, and intestinal hemorrhage — are seldom met with 
in children under five years. Careful palpation of the abdomen may 
disclose the presence of enlarged mesenteric glands. When these are 
not readily felt through the abdominal walls, they may sometimes be 
discovered by a rectal examination. 

The spleen is often enlarged, sometimes very much so, but this does 
not occur with sufficient frequency to be of much diagnostic value. It 
may be due to tuberculous deposits, to causes connected with the lungs 
or heart, or to fever. The liver is not often enlarged from tuberculous 
deposits, but may be so from amyloid or fatty degeneration, or from 
obstructed circulation, as in the case of the spleen. 

Dropsy is rare. It may depend upon anemia, upon complicating 
nephritis, especially amyloid degeneration, upon cardiac or pulmonary 
conditions leading to interference with the return circulation, or upon 



1092 THE SPECIFIC INFECTIOUS DISEASES 

pressure of tuberculous retroperitoneal or mesenteric glands upon the 
inferior vena cava. Clubbing of the fingers is occasionally seen in cases 
running a very protracted course. 

Anemia is commonly associated with wasting, and it is of special 
importance when the latter is slight or absent. It is a frequent sequel 
of acute disease in infancy when not dependent on tuberculosis ; when, 
however, it is associated with low fever, cough, and persistence of rales 
in the chest, it should excite apprehension. 

Chronic Tuberculous Pneumonia. — In young children this is a 
chronic interstitial pneumonia associated with tuberculous deposits. 
These cases have usually had their beginning in one of the acute forms. 
There is a slow convalescence and apparent recovery, although this is not 
complete. Often a slight cough remains, or returns from the slightest 
exposure or other exciting cause. The child does not regain his former 
weight or vigor, and careful examination of the lungs shows that some 
abnormal signs remain. 

After a few months, possibly, the child has another attack resembling 
the first. It is accompanied by fever, cough, and perhaps there is a 
fresh consolidation of some part of the lung, generally in the neighbor- 
hood of the old disease. All active symptoms finally subside, and most 
of the signs of recent disease disappear ; but it is then usually found that 
the condition of the lung is not quite so good as before this second 
illness. The acute attacks may be repeated several times and pass 
under the name of bronchitis, bronchopneumonia, or pleurisy. They 
may extend over a period of years. The general health in the interval 
is not good, there being present in most cases anemia, with the usual 
symptoms of malnutrition; these children are regarded as very delicate. 

The course of this disease thus differs in no essential particulars from 
that of simple chronic bronchopneumonia; the physical signs likewise 
are identical in character, although they may differ in their location. 
They are generally found in the same conditions as are the signs in the 
more rapid forms of pulmonary tuberculosis in early childhood. A fatal 
result in these cases is usually brought about by the development of acute 
tuberculous pneumonia or miliary tuberculosis of the lungs, by tubercu- 
lous meningitis, or by a simple bronchopneumonia. 

Physical Signs of Pulmonary Tuberculosis. — Speaking gener- 
ally, except in situation there is little difference in a young child between 
the signs of a bronchitis or bronchopneumonia due to the tubercle bacil- 
lus, and those of the same lesions when due to other causes. Cavities, 
although present at autopsy in most of the advanced cases, are seldom 
of si i cli size or so situated as to be recognized during life. In children 
over six or seven years old, the signs are essentially like those in adults. 

The upper lobes are the seat of the most advanced disease twice as 



TUBERCULOSIS 1093 

frequently as the lower lobes, and the right lung rather more frequently 
than the left. The region most often involved is the middle zone of the 
lung. If the signs appear first behind they are usually in the inter- 
scapular space ; if in the lateral part of the chest, they are in the middle 
or upper part of the axilla ; if in front, they are in the mammary region. 
The explanation is found in the fact that the disease in infants and 
young children so often extends from the lymph nodes at the root of the 
lung to the lung itself. The physical signs themselves may be grouped 
under four heads, corresponding to the pathological conditions existing 
in the disease, viz., (1) bronchitis; (2) partial consolidation; (3) com- 
plete consolidation; (4) excavation. The early signs are almost identi- 
cal with those described in bronchopneumonia. As a rule, however, the 
transition of the signs from one stage to another is much slower in tuber- 
culous than in simple bronchopneumonia. 

Tuberculous bronchitis gives rales which may be of all sizes and 
varieties, localized or general. If the process goes on to a partial con- 
solidation there are gradually developed in addition slightly impaired 
resonance or even dulness, bronchovesicular respiration, and increased 
voice. These signs are usually over a localized area. Later the signs of 
complete consolidation are present — marked dulness, increased fremitus, 
bronchial respiration, and voice, — but still rales and friction sounds are 
generally heard. 

The later signs depend upon what course the pathological process 
follows. If it terminates in a diffuse or localized caseation, the signs 
differ little from those of a lobar pneumonia with extensive and complete 
consolidation except that the dulness on percussion is usually greater. 
There may be even flatness so marked as to suggest the presence of a 
pleural effusion. Empyema is the diagnosis often made. These signs 
may persist until the death of the patient from exhaustion. 

If the caseation is localized and followed by excavation, the signs 
of a cavity may be present. Cavities, however, are often so small and 
deeply seated as not to give definite physical signs. Furthermore, they 
are frequently filled with thick pus or cheesy matter, and rarely com- 
municate freely with the bronchi. If large and superficial they give the 
same signs as in adults. Like the areas of tuberculous pneumonia, they 
are most frequent in the middle zone of the lung in front or laterally. 
In the young child similar signs are often present when there arc only 
dilated bronchi associated with a fibroid condition, or when a superficial 
bronchus is surrounded by an area of diffuse caseation. Cavities are very 
often diagnosticated when they do doI exist, and quite as often overlooked 
when present. 

If the acute process terminates in a, chronic tuberculous pneumonia 
the signs are those of an unresolved or slowly resolving pneumonia, in 



1094 THE SPECIFIC INFECTIOUS DISEASES 

which the area of consolidation gradually diminishes, but the signs do 
not altogether disappear. When recovery goes further there may remain 
only some dulness on percussion, bronchovesicular respiration, rales, and 
friction sounds. Such signs may last indefinitely, exacerbations and 
remissions occurring from time to time. These signs can not be dis- 
tinguished from those of simple chronic bronchopneumonia. 

Diagnosis or Pulmonary Tuberculosis. — The family history, sur- 
roundings and previous condition of the patient are important, also the 
mode of onset, the course of the disease, and the evidence afforded by the 
physical examination. Not only should the health of the parents and 
other children be investigated, but that of other members of the house- 
hold and frequent visitors. The occurrence of bone and joint disease as 
well as pulmonary disease should be considered. Surroundings favoring 
the development of tuberculosis are city residence, especially if in a tene- 
ment house, or an institution. One should regard as important, habitual 
underweight, anemia and general malnutrition. Of previous diseases in 
the patient the most significant are pneumonia, measles or pertussis with 
prolonged convalescence, and persistent or frequently recurring attacks of 
bronchitis. In the milder or early cases the two important symptoms are 
cough and fever; the cough is more significant when persistent and 
accompanied by mucopurulent expectoration. Hemoptysis among chil- 
dren is so rare as to aid little in diagnosis. Fever, to be of diagnostic 
value, should be at least 99.5° F. in the mouth or 100.5° F. rectal for a 
considerable period, usually several weeks. Wasting is important when 
present but its absence by no means excludes tuberculosis, since it depends 
more upon the condition of the digestive organs and the feeding than 
upon the local disease. Sweating is not a common symptom in children. 
The physical signs which are of especial diagnostic value are persistent 
localized rales anteriorly, either in the region of the nipples, or between 
the nipples and axillae, or at the apices. To these signs should be added 
a positive von Pirquet reaction, which test should be repeated at least 
once to avoid error. Additional information is sometimes afforded by the 
X-ray examination, though the plates need to be interpreted by one with 
much experience. These findings are always to be taken in conjunction 
with physical signs and rational symptoms. 

In the more acute or more advanced cases, tuberculosis has to be 
distinguished chiefly from simple bronchopneumonia. The onset of sim- 
ple pneumonia is usually rapid, often abrupt; tuberculous pneumonia 
usually develops more gradually. Constitutional symptoms may precede 
the local ones by several days or even weeks. In tuberculosis one is often 
struck by the disproportion between the general symptoms and the phys- 
ical signs. One may see with tuberculosis, rapid wasting, prostration, 
cough and high fever with physical signs which are few, irregular and 



TUBERCULOSIS 1095 

inconstant. Again strongly suggestive of tuberculosis are very extensive 
physical signs, especially persistent generalized fine rales without con- 
solidation, accompanied by severe dyspnea, even cyanosis, and yet with 
a temperature only moderately elevated. 

The course of the temperature can not be depended upon in diagnosis. 
A high leucocyte count, e. g., above 25,000, especially when accompanied 
by a high polymorphonuclear percentage, strongly favors pneumonia. 
The X-ray examination is often of more value in these than in the less 
acute cases. The cutaneous tuberculin test gives positive results in nearly 
all cases except those which are extremely prostrated. Meningitis de- 
veloping during a pulmonary disease of doubtful character is generally 
tuberculous. But acute pneumococcus meningitis may occur in very 
similar circumstances. 

Examination for Bacilli. — Discovery of the bacilli in the sputum is 
of course conclusive and is by no means so difficult, even with very small 
patients, as has been supposed ; but in most cases repeated examinations 
are necessary. Infants do not expectorate, but cough up the bronchial 
secretion into the pharynx and swallow it. Sputum must therefore 
usually be obtained from the pharynx. To obtain the sputum in an 
infant one should excite a cough by irritating the pharynx, and then catch 
upon a small swab the sputum brought up into view. By the procedure 
mentioned it is not usually more difficult to obtain good sputum in very 
young patients than in adults. Bacilli are seldom found in clear, glairy 
mucus, but in mucopurulent masses. Following the method described, 
bacilli have been found in the great majority of our hospital cases of 
pulmonary tuberculosis in infants, although in more than half of them 
the disease was not advanced, judging by symptoms and physical signs. 

Bacilli may readily be found in the stools of many children suffering 
from tuberculosis. Their presence does not necessarily indicate a tuber- 
culous lesion of the intestines, for their source is more frequently a 
pulmonary lesion, the bacilli being coughed up and swallowed. Hence, 
it is sometimes easier to find them in the stools than in the sputum. 
They must be carefully differentiated from the smegma bacilli. 

III. Chronic Phthisis. — This form of tuberculosis, with its chronic 
hectic fever, slow cavity-formation, progressive emaciation, night sweats, 
etc., is very rarely seen before the fifth year, and it is not at all frequent 
until the tenth or twelfth year. In its symptoms, course, termination, 
and physical signs, it resembles the same disease in adults, and need noi 
be described at length here. 

IV. Tuberculosis of the Bronchial Lymph Nodes (Bronchial Glands). 
— This condition is usually associated with some form of pulmonary 
tuberculosis, but it may exist as altogether the most important tuber- 
culous lesion. 



1096 THE SPECIFIC INFECTIOUS DISEASES 

The symptoms" are usually associated with those of pulmonary or gen- 
eral tuberculosis ; but they may occur when the pulmonary changes are 
too few to be recognized either by symptoms or physical signs. From the 
great frequency with which this lesion is found in infants and young 
children, it might be expected that local symptoms would be common 
in such patients. They are, however, in our experience, quite exceptional. 
Most of the cases in which well-marked symptoms occur are in children 
over two years old, and it is between the third and tenth years that they 
are usually seen. In infancy, death in most cases occurs from the pul- 
monary disease. 

General symptoms may or may not precede the local ones. The 
latter are chiefly mechanical, and depend upon the size of the glands and 
upon their anatomical relations, and very little or not at all upon the 
nature of the changes in them. The most important relations, so far as 
the production of symptoms is concerned, are those which they bear to 
the pneumogastric and recurrent laryngeal nerves, the superior vena 
cava, the trachea, and bronchi ; those less important are to the aorta, 
pulmonary artery, and esophagus. 

Pressure upon or irritation of the pneumogastric or recurrent nerves 
produces cough, dyspnea, and sometimes a change in the voice. The 
cough is hoarse, persistent, and teasing, and frequently occurs in parox- 
ysms which in many respects resemble those of pertussis, but it usually 
lacks the characteristic whoop, and is not accompanied by the expectora- 
tion of a mass of tenacious mucus. These paroxysms are severe and often 
prolonged. The dyspnea, like the cough, is paroxysmal, and sometimes 
strongly resembles ordinary spasmodic croup; at other times it is like a 
severe attack of asthma. Such symptoms may come and go, but they are 
frequently prolonged, and usually in the interval between the severe 
seizures the patient is not wholly free from dyspnea. Although the chief 
cause of dyspnea is no doubt nerve irritation, it may be due in part to 
pressure upon the trachea or one of the large bronchi. In dyspnea from 
pressure on the trachea the head is usually thrown back, and the obstruc- 
tion is more frequently on expiration than on inspiration. 

After such symptoms as those mentioned have existed for a few days 
or weeks, and in some cases without any warning, there may occur a sud- 
den attack of asphyxia which may prove fatal. This is generally due to 
ulceration of a caseous gland into the trachea or a large bronchus and 
the escape of a large mass into the air passages, where it produces the 
same effects as does any other foreign body. 

Of fifteen cases of this kind collected by Loeb, death by suffocation 
occurred in most in from five to ten minutes after the first definite symp- 
toms; in some the fatal attack was preceded for some time by milder 
attacks or by a cough; in others no previous symptoms were present, 



TUBERCULOSIS 1097 

the child being apparently in perfect health. Rarely after ulceration into 
the trachea the patient has recovered after coughing np a large amount 
of pus. 

Pressure npon the superior vena cava is usually associated with spas- 
modic dyspnea and cough, and causes cyanosis of the face and blueness 
of the lips. There is frequently a puffiness of the face, and there may 
be marked edema. The coexistence of cyanosis with such edema, when 
the urine is free from signs of renal disease, should always lead one to 
suspect pressure at the root of the lung. In some rare cases the interfer- 
ence with the return circulation has been so marked that meningeal 
hemorrhage has resulted. By a process of ulceration set up in these 
glands they may open, not only into the air passages, but into the peri- 
cardium, the esophagus, or any of the large vessels. The last mentioned 
is usually followed by instant death. Aldibert reports two cases in 
which the pulmonary artery was opened, death occurring from hemoptysis, 
as there was also a communication with one of the large bronchi. In 
Yogel's case the subclavian vein was perforated, and death resulted from 
the entrance of air. If ulceration takes place into the surrounding con- 
nective tissue, a mediastinal abscess may result, producing any of the 
pressure symptoms noted above, and, in addition, dysphagia from pres- 
sure on the esophagus. Such an abscess may point in the suprasternal 
notch ; it may open through the chest anteriorly between the ribs or at the 
xiphoid cartilage ; or it may burrow along the esophagus to the peritoneal 
cavity. As a rule, however, patients die of general tuberculosis before 
the local conditions have advanced so far. 

Physical Signs. — In order to produce signs the mass of lymph nodes 
must be large enough to form a considerable mediastinal tumor, or be so 
situated as to produce pressure upon the trachea or bronchi. Only large* 
packets of glands can be made out by physical signs. The large masses 
may give dulness over the first piece of the sternum, or, more frequently, 
behind in the interscapular space, usually between the third and seventh 
dorsal vertebrae. Normally, whispered bronchophony usually ceases at or 
just below the level of the fourth dorsal vertebra. When it extends below 
this point it is suggestive of enlarged bronchial glands (D'Espine's sign). 
It is usually more marked upon the right than the left side. There may 
be also voice and breathing of a somewhat amphoric but with a distinctly 
nasal quality. The signs are sometimes indistinguishable from those 
heard over a small cavity. Taken in connection with a positive cutaneous 
tuberculin test and X-ray findings, these signs are of much significance. 
If one of the primary bronchi or one of ils lobar divisions is compressed, 
there may be very feeble respiration over one lung or one lobe; if (he 
pressure is sufficient to prevent the entrance of air, or if one of these 
large tubes has been plugged by a caseous mass, there is an absence of 



1098 



THE SPECIFIC INFECTIOUS DISEASES 



respiratory murmur over a single lobe or an entire lung. This sign is of 
great diagnostic value, but it is not often present. 

Diagnosis. — Mediastinal glandular tumors may occur in Hodgkin's 
disease and in malignant disease; but both are relatively very rare and 
usually present other diagnostic symptoms. Practically, in almost every 
case, marked enlargement of the bronchial glan,ds is due to tuberculosis. 
The only really trustworthy means of diagnosis in most cases is afforded 
by the X-ray, though considerable experience is requisite in the inter- 
pretation of the plates; the radiographic shadow usually shows better 




Fig. 



180. — Tuberculous Bronchial Glands. A very large mass upon the right side, 
A, A; a smaller one upon the left side, B, B. 



on the right side than on the left on account of the heart (Fig. 180). 
Especially significant are evidences of calcification, which may be found 
even in very young children. (We have autopsy records of such changes 
in infants only seven months old.) More stress is in some cases to be 
laid upon symptoms than physical signs for diagnosis; the most im- 
portant symptoms are the association of a spasmodic cough with parox- 
ysms of dyspnea resembling asthma or croup and severe congestion or 
edema of the face. The chief difficulty in diagnosis is found in those 
cases which present few or no other signs of tuberculosis, and which 
come first under observation with attacks of dyspnea or asphyxia resem- 
bling those seen in laryngeal stenosis. In many such cases tracheotomy 
has been done without finding any cause for the dyspnea, the autopsy 



TUBERCULOSIS 1099 

showing it to be due to the ulceration and impaction of a caseous gland. 
The development in a child of a chronic abscess in the anterior mediasti- 
num is almost always due to tuberculous glands; and so is one in the 
posterior mediastinum, provided Potfs disease can be excluded. 

The Tuberculin Tests. — For general diagnostic use in children von 
Pirquet's cutaneous test is so far superior to the other tests suggested that 
only this need be considered in detail. 

The forearm is the most convenient part for applying the test. The 
skin is carefully washed with alcohol or ether. A small drop of pure 
tuberculin (Koch's O.T.) is placed upon the .skin. With an instru- 
ment resembling a tiny chisel a very slight scarification for control is 
made at a distance of two or three inches from this drop. A similar 
scarification is then made through the drop. Linear scratches one-quarter 
inch in length lightly made with a sterile needle, serve equally well as a 
means of inoculation and control. The child should be watched, and if 
very young the arm should be held until the skin is quite dry to prevent 
infection by rubbing. As an added precaution it may be covered with 
a piece of sterile gauze. The reaction consists in a red areola about the 
point or along the scratch made. This generally begins in from twelve 
to eighteen hours, rarely later than twenty-four hours, and reaches 
its height during the next twenty-four hours. The size of the areola 
indicates the degree of reaction. It continues in most cases for from 
one to three days and slowly fades, often being followed by a slight 
local desquamation. Earely there may be vesiculation. There is in most 
of the cases slight induration of the skin readily appreciable to the touch. 
The more marked reactions continue for from four to ten days. Any 
definite inflammatory reaction which follows this course may be regarded 
as positive. The arm should be observed daily to note the results. There 
seems to be no relation between the intensity of the reaction and the 
extent or the activity of the tuberculous disease. 

The Significance of the Tuberculin Test. — The cutaneous test gives 
positive evidence if tuberculosis is present, in all except the most pros- 
trated cases and those in the late stages of the disease, when diagnosis 
is rarely difficult from the other symptoms. Exceptions arc, in our 
experience, extremely rare. Much importance is therefore to be attached 
to a negative reaction. For greater certainty the test should be repented 
in suspicious cases. The interpretation of a positive reaction is much 
modified by the age of the patient. Under one year a positive reaction 
usually indicates an active tuberculous process. Many have even taken 
the ground that an infant under one year with a positive reaction is 
doomed. We do not think the outlook quite so hopeless ; hut such a reac- 
tion is certainly of grave import. During the second year a positive 
reaction is not so serious; it is often seen in infants who have not at the 



HOO THE SPECIFIC INFECTIOUS DISEASES 

time and do not develop active tuberculosis. After infancy the test be- 
comes less and less an indication of an active tuberculosis and the inter- 
pretation of a positive reaction is more difficult. It is always to be taken 
in conjunction with the clinical symptoms. A negative reaction with 
clinical symptoms suggestive of tuberculosis is always to be regarded as 
significant. It almost certainly excludes tuberculosis except in condi- 
tions of extreme prostration. Great difficulty may exist in the interpre- 
tation of a positive reaction under two conditions. The first is in an 
apparently healthy child with a prolonged unexplained temperature but 
no physical signs of pulmonary disease. In such circumstances the 
existence of active tuberculosis is probable after other conditions have 
been excluded. The X-ray may shed light upon the case. The second 
condition includes the cases in which acute pulmonary disease is pres- 
ent in a patient who gives a positive reaction. The course and ter- 
mination of the disease may ultimately establish the fact that the 
process in the lung was non-tuberculous. But because of the positive 
reaction grave suspicion of tuberculosis may exist. Much needless alarm 
may therefore be excited by a positive reaction, which really demonstrates 
only that the child has somewhere a tuberculous focus, but does not 
prove the existing disease to be a tuberculous process. The tuberculin 
reaction is always to be interpreted in conjunction with the general symp- 
toms and the physical signs. As a rule, in older children a negative 
reaction is of more significance than a positive one. During active 
measles the test can not always be relied upon. 

The tuberculin test should not be allowed to displace the examination 
for bacilli either in the sputum or cerebrospinal fluid, though the latter 
involves much more labor. The positive reaction furnishes reliable evi- 
dence of the existence of a tuberculous process, but as to whether this is 
active or latent gives no information. 

Tuberculides of the Skin. — These are at times of considerable value 
in the diagnosis of general tuberculosis. Although seldom seen in the 
most acute varieties, they are not uncommon in the more slowly pro- 
gressing forms. The distribution of the lesions is fairly constant. They 
are found chiefly on the buttocks, lower abdomen, genitalia and 
thighs. The number present is generally small, half a dozen to a dozen ; 
but they are sometimes numerous and may be widely distributed. The 
lesion somewhat resembles that of varicella. It begins as a minute red 
papule, which is soon surmounted by a small vesicle. This dries to form 
a crust. If the crust is removed a small pit-like depression remains 
which heals quickly, leaving a white, glistening scar surrounded by a 
pigmented border. The lesion runs its entire course in two or three 
weeks. Tubercle bacilli are often present in the lesions but are difficult 
to demonstrate. Tuberculides of the skin in young children are evidence 



TUBERCULOSIS 1101 

of a widely disseminated process and are a very bad prognostic sign. 
Such patients rarely survive more than a few weeks. 

General Prognosis of Tuberculosis. — The outlook for a child under 
two years with general or pulmonary tuberculosis is very bad. So long 
as the disease remains confined to the lymph nodes, the child is not 
usually in danger, except from accidents connected with their softening 
and ulceration, which after all are rare. Spontaneous cure may occur 
in these glands in the same way as in others in the body, viz., by encap- 
sulation, calcification, etc. Such a result is no doubt a very frequent one ; 
exactly how often it occurs it is impossible to say; but when once the 
disease has gained any headway in the lung itself, its steady, advance is 
almost certain to be the course in a young child. In those who are older 
and have more resistance the chances of an arrest of the process are much 
greater. 

If the bacilli have gained entrance into the body in any considerable 
numbers, even though they are shut up in an encapsulated, caseous, 
bronchial gland, the patient is never free from the danger of general 
infection. 

Prophylaxis. — The prevention of tuberculosis must have constant ref- 
erence to its cause. The first essential is the destruction of the tubercle 
bacilli wherever they exist. Since most of those existing in the air 
are derived from the sputum of patients affected with pulmonary tuber- 
culosis, it should be insisted upon, everywhere and at all times, that the 
sputum from such cases should be collected in special cups or cloths and 
destroyed either by germicides or by fire. The next point is to avoid need- 
less exposure. A tuberculous mother should on no account nurse her child 
nor kiss it upon the mouth. A wet-nurse likewise should be free from 
any tuberculous taint. No nurse or other care-taker should ever be 
employed about children who has, or ever has had, pulmonary tuber- 
culosis. It is wise to exclude also those who suffered when children from 
tuberculosis of the bones or the cervical glands, although the danger 
from such persons is extremely slight. If active tuberculosis exists in 
any member of the family, a young child should be kept away from the 
room, and if possible should not reside in the house. On no account 
should infected persons be allowed to kiss children or sleep in the same 
bed with them. The danger from dyinking-cups and oilier dishes should 
not be forgotten. A tuberculous person should either have his special 
dishes, or the utmost care should be taken to boil all those which he has 
used. Cows whose milk is used for children should he under regular 
veterinary inspection and should have passed the tuberculin test. In any 
case when the slightest doubt regarding the health of the cows exists, or 
when the source of the milk is unknown, the milk should be pasteurized. 
The danger of infection through the alimentary canal is very much les< 



1102 THE SPECIFIC INFECTIOUS DISEASES 

than through the respiratory tract, and consequently the precautions first 
mentioned are much more important than those relating to the food, 
although the latter should on no account be neglected. 

In the case of delicate children and those with tuberculous parents or 
with other tuberculous near relatives, everything possible should be done 
to fortify them against the disease. They should be kept under more or 
less constant medical supervision. Attacks of bronchitis or broncho- 
pneumonia should be watched with the greatest solicitude. Exposure to 
influenza, measles or pertussis should especially be avoided. The coun- 
try rather than the city should be chosen for residence, and the child 
should, if possible, spend the winter and spring in some warm, dry cli- 
mate. Parents should be distinctly taught that watchfulness and care do 
not mean coddling or the keeping of children in the house the greater part 
of the time. Such children should live as much as possible in the open 
air, and every form of sport encouraged which tends to keep them there. 
Overheated houses are one of the most prolific agencies in perpetuating 
a delicate condition of health. Plenty of fresh air in sleeping apart- 
ments should always be insisted upon. All catarrhal troubles of the nose 
and pharynx should receive early and prompt attention, especially should 
hypertrophied tonsils and adenoid growths of the pharynx be removed, 
since these are conditions which form a most favorable nidus for the 
growth of tubercle bacilli. 

Treatment of General and Pulmonary Tuberculosis. — If fresh air and 
a proper climate are necessary for the cure of this disease in adults, they 
are tenfold more necessary in the case of children. Without them there 
is little hope for a child with active pulmonary tuberculosis. Nowhere 
do these cases do so badly as in a hospital located in a city, and no class 
of hospital cases do worse than these. The same regions that are bene- 
ficial for adult cases usually agree with children, with the exception that 
the latter, as a rule, do better in a warm than in a cold climate. Plenty 
of fresh air and sunshine are essential. A child must be where he can 
be kept in the open air for the greater part of each day, in spite of 
fever, cough, or other acute symptoms. 

For the most acute cases when, the children are confined to the bed, 
the largest, best-ventilated, and sunniest room available should be secured, 
and the windows should be constantly open. The general management of 
such cases is the same as for those with acute pneumonia. 

There is no specific remedy for tuberculosis. The diet is a matter of 
the utmost importance. Tuberculous patients must be fed like most 
other sick children, care being taken not to disturb the digestion by the 
unnecessary use of drugs. For a staple article of diet, milk is the best, 
and when this is not well borne some of its substitutes — buttermilk, 
kumyss, zoolak, etc. — may be tried. Cream is almost as useful as cod- 



SYPHILIS 1103 

liver oil, and should be given in one form or another whenever the 
child's digestion can tolerate it. 

Tuberculin in the treatment of this disease in young children has been 
most disappointing in its results. Its value has not yet been demon- 
strated. There always exists the possibility of lighting up a latent process 
in the lungs. Tt should be given with the greatest caution in active febrile 
cases. The method of using it is discussed under the treatment of Tuber- 
culous Adenitis. 

Cod-liver oil is usually best given in a fresh emulsion, although some 
children bear the pure oil better than its preparations. Inunctions of 
this or other oils are of some value when not well tolerated by the stom- 
ach. Arsenic and iron are useful as general tonics. 



CHAPTER XI 
SYPHILIS 



Syphilis is a communicable disease due to a specific organism, the 
spirocheta pallida of Schaudinn. In acquired syphilis this is found in 
the primary lesion, in the mucous patches and in the lymph nodes. In 
hereditary syphilis it is found in the cutaneous lesions, in the fissures 
at the angle of the mouth and in the mucous patches of the buccal 
cavity, with less regularity in the internal organs, except the liver, which 
usually harbors the organism in immense numbers. While in the still- 
born child and in early cases, the number of organisms found is very 
great, they are not so numerous at a later period, and they diminish rap- 
idly after treatment is begun. In the late lesions the spirochetae are 
not numerous, and are difficult to demonstrate. 

In infancy and childhood both the acquired and the hereditary forms 
of syphilis are seen. 

ACQUIRED SYPHILIS 

While acquired syphilis is very much less frequenl than the hered- 
itary variety, it is by no means a very rare disease in early life. It is qoI 
improbable that some of the manifestations of syphilis in later childhood 
which are usually denominated "late hereditary syphilis," arc really dm 1 
to the acquired form. 

Etiology. — An infant may be infected by the mother during parturi- 
tion; but this is extremely rare and can take place only when there are 
lesions upon the mother's genitals. Infection is more likely to be from 



1104 THE SPECIFIC INFECTIOUS DISEASES 

a mother who contracts syphilis subsequent to the birth of the child, 
and may occur through nursing or accidental contact by kissing, etc. 
In either of these ways, or from a venereal sore upon the nipple, a child 
may be infected by a wet-nurse. Whether syphilis can be communicated 
through the milk when the nipple is perfectly healthy and free from 
fissures, is exceedingly doubtful. 

Syphilis may be communicated directly from a syphilitic child to one 
who is healthy, by kissing, by sexual contact, or indirectly by means of 
bottles, spoons, cups, clothing, etc. The latter mode of infection is most 
likely to occur in institutions. Vaccination was formerly a not infre- 
quent mode of communicating syphilis, but has been practically elimi- 
nated by the general introduction of bovine virus. Cases have been re- 
corded where the disease has been conveyed by the rite of circumcision, 
either from the mouth or the instruments of the operator. 

The relative frequency of the different sources of infection is shown 
by Fournier's statistics of 40 cases: The source of infection was the 
parents in 19; nurses, in 8; servants, in 4; sexual contact, in 4; vaccina- 
tion, in 2 ; other children, in 2 ; a physician, in 1. The ages at which 
the disease was acquired in this series of cases were as follows : During 
the first year, 19 ; during the second year, 10 ; during the third and 
fourth years, 7 ; from the fifth to the fourteenth year, 6. 

Symptoms. — The symptoms of acquired syphilis in children are in all 
respects similar to the same disease in the adult. A primary sore is 
present at the site of infection, which is most frequently the lips, the 
mouth, or some part of the face; very rarely is it seen on the genitals. 
There are few individual symptoms belonging to hereditary syphilis which 
may not also be present when the disease is acquired. Its course, how- 
ever, is very much milder in the latter and a fatal termination is rare. 
Fournier states that of his forty-two cases only one died of marasmus. 
This marked contrast to hereditary syphilis is due chiefly to the fact that 
in the acquired variety the infant is rarely infected during the early 
months of life, a time when hereditary syphilis is so fatal. 

Tertiary symptoms may appear at any time from three to twenty 
years after the original infection. 

The treatment is the same as that of hereditary syphilis. 

HEREDITARY SYPHILIS 

Etiology. — If both parents are syphilitic, the child is usually but not 
invariably so. The symptoms, however, are not more severe than when 
the inheritance is from one parent only. The likelihood of transmission 
depends upon the stage of the disease in the parents. If the mother 
is suffering from secondary symptoms, transmission is almost certain. 






HEREDITARY SYPHILIS 1105 

If active treatment has been employed for several months, if the child is 
born at a period when no active symptoms are present, or if the symptoms 
are of a tertiary character, the offspring will probably escape. First-born 
children are more likely to suffer severely from syphilis than the later 
ones, provided infection of the parents has taken place prior to the birth 
of all the children. 

The transmission of syphilis from the father without the intermedi- 
ate infection of the mother was once held to be not only possible but fre- 
quent. At the present time, however, this question must be placed among 
those not yet definitely settled. There can be no doubt that in the vast 
majority of the cases the infection of the child is from the mother. 

If both parents are healthy at the time of conception and the mother 
becomes infected during her pregnancy the child may or may not be 
syphilitic. Transmission to the child is much less likely to occur if the 
mother is infected during the last two months of her pregnancy than 
earlier, although, as Hutchinson's cases conclusively show, there is no 
certainty that the child will escape. Diday states that if the mother is 
infected before the fourth week and proper treatment is instituted, the 
child will usually escape on account of the relation of the embryo to the 
maternal circulation during this early period. 

In 1837 Colles enunciated the following proposition, the truth of 
which has been abundantly verified since his time : "A new-born child 
affected with inherited syphilis, even although it may have symptoms in 
the mouth, never causes ulceration of the breasts which it sucks if it be 
the mother who suckles it, although continuing capable of infecting a 
strange nurse." From the careful analysis of many cases and with the 
great assistance derived from the Wassermann reaction the conclusion 
seems irresistible that the mother who bears a syphilitic child is immune 
to syphilis for the reason that she herself is suffering from syphilis, or 
a modification of that disease. The mother in these circumstances can 
not be inoculated either by her syphilitic nursing infant or artificially. 

That hereditary syphilis is contagious is conclusively shown by a 
number of recorded instances in which a healthy wet-nurse has been 
infected by a syphilitic infant. "We have ourselves seen one such instance. 
However, such examples of contagion are rare, and many writers of large 
experience state that they have never seen it. It is certainly true that 
the danger of spreading infection from a case of hereditary syphilis has 
been exaggerated. 

Lesions. — Death may occur with syphilis, and yet the autopsy may 
reveal no characteristic anatomical changes, and in fact there may be 
no demonstrable changes in any of the organs except the presence of the 
spirochetal This is particularly true of infants dying in the first weeks 
of life. 



1106 THE SPECIFIC INFECTIOUS DISEASES 

Bones. — In the case of a syphilitic fetus, a still-born child, or one dy- 
ing soon after birth, the changes in the bones are more uniformly present 
than are any other lesions. They are, in fact, rarely wanting, and it is by 
them alone that syphilis is often recognized post mortem, but it may re- 
quire a microscopical examination to establish the diagnosis. The long 
bones are principally affected, the most important changes being found at 
the junction of the shaft with the epiphyseal cartilage. The lesion is 
termed an epiphyseal osteochondritis. There are two varieties: in one 
there is an inhibition of bone formation around the columns of calcified 
cartilage, though the destruction of cartilage cells by the vessel loops and 
the formation of bone marrow goes on unchecked and in a normal man- 
ner. In the other, there is, in addition to the delay in bone formation, 
the development of granulation tissue that springs from the cartilage 
canals and that grows between the shaft and' the epiphysis, and, perforat- 
ing the column of cartilage cells, invades the epiphysis. The granulation 
tissue may grow so luxuriantly as to separate the epiphysis from the shaft 
and in either case the bone is so weakened at the epiphyseal line that 
fracture through it readily takes place as the result of slight traumatism, 
either in intra-uterine life or after birth. Thus results separation of 
the epiphysis, a frequent manifestation of severe hereditary syphilis. 
With either form of osteochondritis there is a broad yellow line to be 
made out macroscopically at tjie junction of the epiphysis and shaft ; with 
the excessive formation of granulation tissue and the invasion of the 
epiphysis the line is an irregular one. 

While the osseous changes are widely distributed throughout the body 
they are not of equal intensity. The lower end of the femur and radius 
and the upper end of the tibia and humerus are most severely affected. 
Complete recovery from the lesion is possible. Acute suppurative epi- 
physitis and arthritis may occur in syphilis but they are to be regarded as 
of pyemic rather than of syphilitic origin. 

Osteoperiostitis is common in hereditary syphilis. In young infants 
it is found as a very generalized lesion, affecting the shafts of the long 
bones, especially those of the leg, forearm, and hands. The swelling is 
usually at the end of the shaft. With increasing age the tendency is to 
involve the shaft nearer its middle. The lesion in infants is largely 
periosteal. Later the bone participates more and more in the process; 
tli ere is a formation of new bone which is firm and very compact or it 
may consist of a coarsely spongy structure. The periosteal swellings 
with appropriate treatment may entirely disappear by absorption. The 
new-formed bone largely persists. 

Gummata of the bones are rare in infancy. With older children 
gummata may form on the long bones or the skull. They are not essen- 
tially different from those occurring with acquired syphilis. 



HEREDITARY SYPHILIS 1107 

Liver. — This is probably more frequently involved in the fetus and 
newly-born infant than any other organ. The syphilitic lesions of the 
liver consist in an interstitial. hepatitis, a gummatous hepatitis, or a com- 
bination of the two varieties. In the interstitial form, which is most fre- 
quent in infancy, the liver is enlarged, frequently very much so, and 
firm. On cross section the markings are indistinct. Microscopically, 
there is a great increase in connective tissue which is diffusely scattered 
throughout the whole organ and even between the individual liver cells. 
There may be also bands of connective tissue invading the liver in dif- 
ferent directions. As the connective tissue contracts an irregularity of 
the surface of the liver develops. Groups of miliary syphilomata may also 
be found. 

The gummatous form is not frequent in early infancy, but belongs to 
a little later period. In this there may be miliary syphilomata with 
interstitial changes, and in addition the formation of small or large 
gummatous tumors which may be softened at the center. They are sur- 
rounded by zones of new connective tissue and the liver cells are 
atrophied. Amyloid changes may be present. 

In the late form of hereditary syphilis, usually seen in children over 
four or five years old, the liver is occasionally affected. The lesions 
resemble those of the congenital variety. There are found cirrhotic 
changes, which may be diffuse or circumscribed, and gummatous deposits, 
which vary from a minute size to that of a cherry ; there may be amyloid 
degeneration. 

Spleen. — This is almost invariably much enlarged in newly-born chil- 
dren with syphilis and in syphilitic fetuses, but nothing characteristic is 
found under the microscope. In older children the enlargement of tin 1 
spleen may be even greater. The organ may be the scat of interstitial 
changes, and sometimes there may be small gummatous deposits. These 
changes are rare in children under two years of age. 

Respiratory System. — In syphilitic infants who arc still-born ami in 
those who die soon after birth, there is occasionally found in the lungs 
what is known as "white pneumonia." The lungs arc nearly white or 
slightly red. They are firm and contain little or no air. The alveoli arc 
filled with desquamated cells and leucocytes. There is an increase in the 
connective tissue of the alveolar walls, bronchi, and blood vessels. There 
may also be gummata scattered through the lungs. These are usually 
small. 

The trachea and bronchi are in rare cases the seat of stenosis, which 
results from cicatrization following the softening of gummatous <I<|k>-ii< 
in their walls. Lesions of the larynx other than a chronic catarrhal in- 
flammation of the mucous membrane, arc also infrequent. The lesion 
usually found is perichondritis, which more often involves the epiglottis 



1108 THE SPECIFIC INFECTIOUS DISEASES 

than any other part. Sometimes there is the formation of papillomatous 
masses; but ulceration and stenosis are both rare. 

The nasal mucous membrane in the early stage of the disease is very 
constantly the seat of a chronic catarrhal inflammation, which may be 
accompanied by superficial ulceration. In the late cases there is deeper 
ulceration, from the breaking down of gummata, with extension to the 
periosteum, cartilages, and bones, causing perforation of the septum, 
necrosis of the bones, etc. 

Nervous System. — Syphilis may affect the meninges, the blood ves- 
sels or the brain itself. There may be merely a diffuse thickening of the 
meninges with which there is usually associated a certain amount of 
encephalitis, or there may be miliary gummata scattered throughout the 
meninges but especially at the base. As the result of the chronic syph- 
ilitic meningitis, adhesions may form at the base, obliterating the fora- 
men of Magendie and at times leading to hydrocephalus. Syphilitic en- 
darteritis is very common and consists in a thickening of the vessel 
wall with proliferation of the intima and reduction in the caliber of the 
vessel. There is also a perivascular proliferation of connective tissue. 
The changes that have been described are found in direct proportion to 
the severity of the syphilitic infection. In infants dying in utero or 
shortly after birth they are frequent. In those with a mild infection, the 
lesions may be slight or absent. Large gummata are unusual at any 
time. 

Later in childhood, syphilis of the brain is not very uncommon. The 
lesions are chiefly the result of the vascular changes and consist in local- 
ized or diffuse sclerosis with greater or less atrophy of the convolutions. 
The lesions of juvenile paresis and tabes do not differ from those that 
are the result of acquired syphilis. 

Heart and Arteries. — These are very frequently affected, even in 
young infants. Adler, of four cases examined, found two in which well- 
marked lesions were present in infants under four months. Warthin 
has emphasized the importance of systematic study of the heart for evi- 
dences of syphilis. He has found lesions and has demonstrated the 
organism when no other evidences of syphilis were to be found in the 
body. The lesions consist of a diffuse or localized interstitial myocarditis 
with endarteritis of the coronary arteries and small blood vessels. 

Digestive System. — Chronic catarrhal pharyngitis is almost a con- 
stant symptom of the early cases. Later there is seen superficial or deep 
ulceration of the pharynx, tonsils, or fauces, which may lead to perfora- 
tion of the soft or hard palate. 

There are no frequent lesions of the stomach or intestines either 
with early or late syphilis. In infants dying early with very extensive 
lesions ulcerations are sometimes found in the small intestine. They are 



HEREDITARY SYPHILIS 1100 

multiple and extend transversely across the intestine. They cause no 
symptoms. The rectum is occasionally the seat of -ulceration, and con- 
dylomata may form about the anus even in young children. 

Pancreas. — Changes in the pancreas are frequent with severe infec- 
tions; with mild infections they are usually absent. They consist in a 
diffuse production of connective tissue which replaces, to a greater or 
less extent, the parenchyma of the organ. In the most extreme cases 
there may be no glandular tissue remaining. The islands of Langerhans 
are usually not destroyed. 

Thymus. — Occasionally there are found in syphilis numerous small 
abscesses in the substance of the thymus gland. They are rilled with a 
purulent material consisting of leucocytes with great numbers of spi- 
rochetes. The glandular tissue is also infiltrated with leucocytes. These 
abscesses of DuBois are very characteristic of syphilis. 

Organs of Special Sense. — Otitis is a frequent accompaniment of the 
early syphilitic pharyngitis. It is very likely to become -chronic, and in 
many cases results in a permanent impairment of hearing. Iritis is rela- 
tively rare in children, but it may occur even in intra-uterine life, as 
shown by the presence of adhesions in newly-born children. It is usually 
seen in infants four or five months old, and is always serious. Interstitial 
keratitis occurs frequently as a later manifestation of syphilis. Choroid- 
itis and optic neuritis are both occasionally seen, but they are rare. 

Genito-urinary Organs. — Nearly all these may be affected, but gener- 
ally in the late period of the disease. There may be chronic interstitial 
nephritis and more rarely gummatous deposits in the kidney, interstitial 
changes in the suprarenal bodies, and orchitis, which usually affects the 
body of the organ, rarely the epididymis; it is generally an interstitial 
inflammation, with or without gummatous deposits. 

Symptoms. — As the result of syphilis, abortion may take place at any 
period of pregnancy, with the discharge of a dead or macerated fetus, or 
the child may be still-born at term, or it may be born alive prematurely, 
but with so feeble a vitality that it survives but a few hours. In these 
circumstances it is often difficult and sometimes impossible to decide 
positively with reference to the existence of syphilis. Maceration of 
the fetus or peeling of the skin is no proof, and even the examination 
of the internal organs may not be conclusive, except for the presence of 
spirochetal Lomer examined 43 fetuses, all dying before the thirtieth 
week of pregnancy; he Pound the spleen and liver enlarged in all, and 
marked bone changes in 21. Birch-Hirschfeld examined 108 aewly-born 
syphilitic infants; he found the spleen invariably enlarged; typical bone 
changes were present in 35, but in many cases the bones were normal. 
More recent studies of the bones have shown them to be involved in a 
much larger proportion of cases than is gives by these writers. Mervis, 



1110 THE SPECIFIC INFECTIOUS DISEASES 

from an examination of 92 syphilitic fetuses, states that no eruption 
upon the skin was found earlier than the eighth month. 

Symptoms are present at birth in only a small number of cases. In 
such there is usually a very severe degree of infection, and the infants 
do not often live more than a few days. Upon the skin there may be 
seen an eruption of pustules, papules, or bullae. The bullae are usually 
upon the soles and palms, but may be found upon other parts of the body. 
The name "syphilitic pemphigus" is often given to this condition. The 
bullae are at first small, then may coalesce and form larger ones two 
inches or more in diameter. They contain a turbid serum which is some- 
times tinged with blood, and sometimes yellow from pus. Pustules, when 
present, are usually seen upon the face or scalp. The general appearance 
of these infants is wretched in the extreme. The body is wasted, the skin 
wrinkled, and temperature subnormal. The spleen is usually enlarged 
and often the liver also. Death usually occurs from inanition within 
two weeks. 

In the great majority of cases the infant appears healthy at birth, 
and continues so for a variable time before the manifestation of the char- 
acteristic symptoms of syphilis. As a rule, the more intense the infec- 
tion, the earlier the symptoms make their appearance. The earliest symp- 
toms are generally seen between the second and the sixth weeks. If 
three months pass without evidence of syphilis, the probabilities are that 
the child will escape. Miller (Moscow) gives the following statistics of 
the time of beginning of symptoms in 1,000 cases : 

Symptoms appeared during the first week 85 cases. 

" second week 138 " 

" third week. 240 « 

" " " " fourth week 177 " 

" "' " « fifth week 86 " 

* * " " sixth week 54 " 

" " " " seventh week 50 " 

" " " " eighth week 30 " 

after the eighth week : 140 " 

Sometimes the constitutional symptoms — wasting, cachexia, etc. — 
are noticed before the local ones, but usually this is not the case. Gener- 
ally the first symptom is the coryza or "snuffles," which resembles an 
ordinary cold in the head, except that it persists. It is often accompanied 
by a hoarse cry, indicating that the larynx participates in the catarrhal 
inflammation. Soon the eruption makes its appearance, being generally 
first seen upon the hands, feet, and face. Fissures and mucous patches 
may be seen upon the lips, about the anus, and elsewhere. There is often 
slight fever, from 99° to 101° F. There may also be observed excessive 
tenderness and swelling about the shoulders, elbows, wrists, or ankles, 



HEREDITARY SYPII1LTS 



1111 



due to epiphysitis, which may cause the child to cry from the slightest 
amount of handling, and the limbs may be moved so little that paralysis 
is suspected. 

In a severe case, as these local symptoms develop, the infant's gen- 
eral nutrition suffers. He loses steadily in weight, he becomes extremely 
anemic, and whines and frets almost continually, but especially at night. 
The features have a pitiful, drawn expression ; the face is wrinkled, giv- 
ing the infant a very old appearance. The skin has a peculiar sallow 
color, which has been well described as cafe au Jait. The symptoms 
may continue until a condition of extreme marasmus is reached, or 
death may occur from some intercurrent affection of the lungs or diges- 
tive organs. Wasting is, 
however, very common in 
infants that are premature 
or very small at birth. Even 
without hereditary syphilis 
the question of nutrition is 
then a difficult one. Indi- 
rectly by causing prematur- 
ity, the syphilis is responsi- 
ble. It is remarkable to see 
how well some children with 
extensive evidences of syph- 
ilis thrive, provided they 
were full-term infants and 
are breast fed. 

In the milder forms of 
infection the severe consti- 
tutional symptoms described 
are not seen, although the 

local evidences of disease are well marked. The severity of the symptoms 
is also much modified by treatment, especially when this is begun 
early. 

The most important local symptoms are the coryza, eruption, fissures 
about the mouth and anus, mucous patches, painful swellings at the ex- 
tremities of the long bones, pseudoparalysis, and onychia. 

Coryza. — In most of the cases this is the first symptom. Beginning 
like an ordinary catarrh, it is distinguished by its severity and its per- 
sistence. There is a copious discharge of mucus and serum, often tinged 
with blood. Thick crusts form, which produce the usual symptoms of 
nasal obstruction; there is great difficulty in nursing; the infant breathes 
through the mouth, and the mucous membrane of the mouth is dry, caus- 
ing great discomfort. If untreated, the process, which at first involves 




Fig. 181. 



Early Eruption of Herkditary Syph- 
ilis. Infant two months old. 



1114 THE SPECIFIC INFECTIOUS DISEASES 

infection, bleeding may occur from the bullous eruption upon the skin, 
or from the fissures at any of the orifices, particularly the mouth and 
anus. Fischl has reported seven cases of multiple hemorrhages in the 
newly born, associated with other symptoms of congenital syphilis. 
Mracek noted hemorrhages in thirty-three per cent of 160 autopsies on 
syphilitic still-born infants or those dying soon after birth. Examination 
of the blood-vessels in some of these cases showed infiltration of their 
walls and narrowing of their lumen. The vascular changes were thought 
to be the cause of the bleeding. 

Nails.. — The nails present several peculiarities in syphilitic infants. 
There may be a disease of the matrix resulting in suppuration and ex- 
foliation of the nail ; frequently the dorsum is much arched, and the nail 
appears as if it had been pinched by a pair of forceps — i. e., claw-shaped ; 
this is an early symptom of some diagnostic importance. The hair and 
eyebrows frequently fall out completely. This symptom is not usually 
present in very early infancy. 

Pseudoparalysis. — This is due to acute epiphysitis, and it may be 
the first symptom of hereditary syphilis to attract attention. It is usu- 
ally noticed when the infant is a few weeks old, that one or more ex- 
tremities is not moved, and that the parts are tender when handled. 
The limb lies perfectly motionless, and any attempt at passive move- 
ment causes evident pain. A history will usually be obtained that the 
loss of power did not exist at birth but developed subsequently. If the 
arm is affected it is very frequently held in marked inward rotation with 
the palm looking outwards, resembling the position in Erb's palsy. There 
is tenderness on pressure, and soon swelling is seen, both being most 
marked at the epiphyseal line. If the bone affected is superficially situ- 
ated, as the lower epiphysis of the humerus, radius, or tibia, swelling is 
very apparent, while it may be scarcely perceptible at the upper epiphysis 
of the humerus. The swelling is usually cylindrical and moderate in 
degree, being limited to the extremity of the bone. Separation of the 
epiphysis may take place, so that crepitation is obtained by moving the 
limb. With this there is sometimes suppuration due to secondary in- 
fection. The X-ray shows in many instances an increase in the width 
of the epiphyseal line which may be very irregular. (Fig. 185.) 

In the milder cases, or those which have been subjected to active 
treatment, both the swelling and the tenderness subside rapidly without 
suppuration ; and even though the epiphysis has separated from the shaft 
it speedily unites. When pseudoparalysis has been the chief symptom, 
very rapid improvement occurs under treatment, and usually there is 
complete recovery of function in two or three weeks. If secondary in- 
fection takes place the condition is usually fatal. 

Syphilitic Osteoperiostitis. — This is usually found in infancy only 



HEREDITARY SYPHILIS 



1115 



as the result of a severe infection. It chiefly affects the long bones, 
especially the tibia, fibula, radius, humerus, phalanges, and metacarpal 
and metatarsal bones. The lesions are multiple, often symmetrical, and 
at this age are principally periosteal. They are generally situated near 
the ends of the shaft. The swellings caused by the periostitis can be 
made out readily when they are but slightly covered by muscles or fat. 
It may, however, be impossible to demonstrate their presence except by 
means of the X-ray. The swellings are firm and often distinctly tender. 
They are frequently associated with the symptoms of syphilitic epiphys- 





Fig. 185. — Hereditary Syphilis. 
Showing irregularity and exagger- 
ation of line A. Infant two 
months old. 



Fig. 186. — Syphilitic Periostitis of the 
Fibula. Infant three months old. 
Same patient as Figs. 187-190 
Right side affected; left side normal. 



itis. The X-ray picture shows a fusiform swelling chiefly due to peri- 
osteal thickening. (Fig. 186.) 

Syphilitic Dactylitis. — This is found in infants usually between the 
third and seventh months. It is not a frequent manifestation of syphilis. 
When present there are usually other evidences of bone syphilis, 3uch as 
periosteal swellings, for the dactylitis is an osteoperiostitis but usually 
differs from that affecting other bones in that the involvement of the 
bone, even at this early age, is considerable and the periostitis rather 
slight. By means of the X-ray it can be seen thai the phalanx involved 
is much thickened and of denser structure than the normal. Excepl Pot 
the fact that more than one and frequently several phalanges are in- 



1114 THE SPECIFIC INFECTIOUS DISEASES 

infection, bleeding may occur from the bullous eruption upon the skin, 
or from the fissures at any of the orifices, particularly the mouth and 
anus. Fischl has reported seven cases of multiple hemorrhages in the 
newly born, associated with other symptoms of congenital syphilis. 
Mracek noted hemorrhages in thirty-three per cent of 160 autopsies on 
syphilitic still-born infants or those dying soon after birth. Examination 
of the blood-vessels in some of these cases showed infiltration of their 
walls and narrowing of their lumen. The vascular changes were thought 
to be the cause of the bleeding. 

Nails. — The nails present several peculiarities in syphilitic infants. 
There may be a disease of the matrix resulting in suppuration and ex- 
foliation of the nail; frequently the dorsum is much arched, and the nail 
appears as if it had been pinched by a pair of forceps — i. e., claw-shaped ; 
this is an early symptom of some diagnostic importance. The hair and 
eyebrows frequently fall out completely. This symptom is not usually 
present in very early infancy. 

Pseudoparalysis. — This is due to acute epiphysitis, and it may be 
the first symptom of hereditary syphilis to attract attention. It is usu- 
ally noticed when the infant is a few weeks old, that one or more ex- 
tremities is not moved, and that the parts are tender when handled. 
The limb lies perfectly motionless, and any attempt at passive move- 
ment causes evident pain. A history will usually be obtained that the 
loss of power did not exist at birth but developed subsequently. If the 
arm is affected it is very frequently held in marked inward rotation with 
the palm looking outwards, resembling the position in Erb's palsy. There 
is tenderness on pressure, and soon swelling is seen, both being most 
marked at the epiphyseal line. If the bone affected is superficially situ- 
ated, as the lower epiphysis of the humerus, radius, or tibia, swelling is 
very apparent, while it may be scarcely perceptible at the upper epiphysis 
of the humerus. The swelling is usually cylindrical and moderate in 
degree, being limited "to the extremity of the bone. Separation of the 
epiphysis may take place, so that crepitation is obtained by moving the 
limb. With this there is sometimes suppuration due to secondary in- 
fection. The X-ray shows in many instances an increase in the width 
of the epiphyseal line which may be very irregular. (Fig. 185.) 

In the milder cases, or those which have been subjected to active 
treatment, both the swelling and the tenderness subside rapidly without 
suppuration ; and even though the epiphysis has separated from the shaft 
it speedily unites. When pseudoparalysis has been the chief symptom, 
very rapid improvement occurs under treatment, and usually there is 
complete recovery of function in two or three weeks. If secondary in- 
fection takes place the condition is usually fatal. 

Syphilitic Osteoperiostitis. — This is usually found in infancy only 



HEREDITARY SYPHILIS 



111; 



as the result of a severe infection. It chiefly affects the long bones, 
especially the tibia, fibula, radius, humerus, phalanges, and metacarpal 
and metatarsal bones. The lesions are multiple, often symmetrical, and 
at this age are principally periosteal. They are generally situated near 
the ends of the shaft. The swellings caused by the periostitis can be 
made out readily when they are but slightly covered by muscles or fat. 
It may, however, be impossible to demonstrate their presence except by 
means of the X-ray. The swellings are firm and often distinctly tender. 
They are frequently associated with the symptoms of syphilitic epiphys- 





Fig. 185. — Hereditary Syphilis. 
Showing irregularity and exagger- 
ation of line A. Infant two 
months old. 



Fig. 186. — Syphilitic Periostitis of the 
Fibula. Infani three months old. 
Same patient as Figs, is? 190 
Right side affected, left side normal. 



itis. The X-ray picture shows a fusiform swelling chiefly due to peri- 
osteal thickening. (Fig. 186.) 

Syphilitic Dactylitis. — This is found in infants usually between the. 
third and seventh months. It is not a frequent manifestation of syphilis. 
When present there are usually other evidences of bone syphilis, such as 
periosteal swellings, for the dactylitis is an osteoperiostitis but usually 
differs from that affecting other hones in thai the involvemenl of the 
bone, even at this early age, is considerable and the periostitis rather 
slight. By means of the X-ray it can be seen that the phalanx involved 
is much thickened and of denser structure than the normal. Excepl for 
the fad that more than one and frequently several phalanges are in- 



1116 



THE SPECIFIC INFECTIOUS DISEASES 



volvecl, the symptoms closely resemble the tuberculous form. The en- 
largement is spindle-shaped, involving the entire phalanx. It is usually 
not painful. It slowly increases in size and but rarely goes on to sup- 
puration or necrosis. The disease may be arrested and cured by consti- 
tutional treatment. 

Lymph Nodes. — These are often palpable. Marked enlargement is 
uncommon. No aid in diagnosis can be obtained from any but the 
epitrochlear glands. If these are considerably enlarged in infancy with- 
out evident adequate explanation, a suspicion of syphilis should always be 
aroused. They may be at times almost the only evidences of the disease. 

The only visceral symptoms of importance are, enlargement of the 




Fig. 187. Fig. 188. 

Figs. 187, 1S8. — Syphilitic Dactylitis. On right hand first phalanges of forefinger and 
little finger affected; on left hand first phalanx of thumb and second phalanx of second 
finger. 



spleen, which is almost invariably present in the active stage of hereditary 
syphilis, and jaundice with or without enlargement of the liver (see 
Icterus of the Newly Born). 

Late Hereditary Syphilis. — The symptoms may come on at any 
period during childhood or about the time of puberty, but rarely at a 
later time than this. They are seen both in those who have had the 
usual symptoms of hereditary syphilis in early infancy, and in others 
where the most careful examination into the history fails to disclose any 
symptoms whatever of early syphilis. It is fair to assume in such cases 
either that early symptoms were absent or that they were of trivial 
importance. 

Late hereditary syphilis shows itself by symptoms which in acquired 
disease would be classed as tertiary. The most characteristic are the af- 
fections of I he teeth, the bones, the eyes, gummatous deposits in the solid 



HEREDITARY SYPHILIS 



1117 



viscera, the skin or mucous membranes, the breaking down of which may 
lead to ulceration, and. finally, symptoms of disease of the nervous sys- 
tem. 

Teeth. — There are no peculiarities in the first teeth of syphilitic chil- 




Fig. 189. Fig. 190. 

Figs. 189, 190. — Same Hands as Figs. 187, 188. Note that besides the bones shown in the 
other pictures, two metacarpal bones (C, D) are affected in the left hand and the 
lower end of the radius (G) in the right hand. 



dren except their proneness to early deca y. They are rather more likely 
to appear early than late. 

The characteristic teeth of syphilis are those of the second set. In 
estimating the diagnostic value of these changes, only the upper central 
incisors are to be relied upon ; these are the test teeth. Although changes 
are frequently seen in other teeth, they are 
not always diagnostic. Typical syphilitic 
teeth, according to Hutchinson, have each a 
single notch in the center of the edge (Fig. 
11)1). The notch is usually shallow and more 
or less crescentic in shape. The enamel is 
generally deficient in the center of the notch, 

and the tooth here is apt to be discolored. The teeth in other cases are 
variously dwarfed and deformed (Fig. 192). They ofteD taper regu- 
larly from the base to the edge, giving rise to the term "screw-driver 
teeth." The teeth often are not SO flat as the normal incisors, but often 
rounded and peg-like. They are qoI properly placed, but incline either 
37 



OCT 

Fig. 191. — Typical "Hutch- 
inson's Teeth." (After 
Founder.) 



1118 



THE SPECIFIC INFECTIOUS DISEASES 



toward or away from each other. They are seldom large enough to 
touch the adjacent teeth on both sides. 

Although Hutchinson's teeth may generally be taken as conclusive 
evidence of syphilis, they are not invariably so, as Keyes and others have 
shown. It is to be remembered in this connection that the absence of 
changes in the teeth is of no importance whatever as evidence that 
syphilis is not present. Hutchinson states that they are wanting in more 
than half the cases. 

Bones. — The form of disease which is usually seen at this period is an 
osteoperiostitis, affecting principally the shaft of the long bones and the 
cranium. Chronic osteoperiostitis is more frequent after the third year, 
and most of the cases occur between the fifth and fourteenth years. The 

most common seat of disease is the tibia, 
and next to this the bones of the 
forearm and the cranium. The follow- 
ing is the frequency with which the dif- 
ferent bones were affected in the series of 
cases reported by Fournier: tibia in 91 
cases, ulna in 22, radius in 15, cranium 
in 16, humerus in 12, all others in 37. 
The process may result either in a diffuse 
or a localized hyperplasia of bone or in 
necrosis. 

The typical changes are seen in the 
tibia. The shaft of the bone is princi- 
pally or solely affected. There is often 
produced a very characteristic deformity, 
consisting of a forward curve of the an- 
terior border of the tibia, which has been compared to a saber blad e 
(Figs. 193, 194). In some cases the bone is bent inward at its lower 
third, resembling somewhat a rachitic curvature. Sometimes the entire 
shaft of the bone is affected, and it may be greatly enlarged. At other 
times the swelling is chiefly near the epiphysis, where large bosses may 
form of sufficient size to interfere with the functions of the joint. In- 
stead of affecting the bone uniformly, the disease often affects only cer- 
tain parts, leading to the formation of large nodes which are more likely 
to be followed by necrosis than are the other lesions. In most of the 
cases the process is purely a hyperplastic one, leaving the bone perma- 
nently enlarged and the limb often lengthened. Less frequently, there 
occur gummatous deposits in or beneath the periosteum, which may 
soften, suppurate, and lead to superficial necrosis, with the formation 
of sinuses that remain open until the sequestrum is exfoliated. Syphi- 
litic deposits sometimes take place in the interior of the bones, generally 




Fig. 192. — Syphilitic Teeth. Boy 
eight years old; under observa- 
tion several years with various 
syphilitic manifestations. 



HEREDITARY SYPHILIS 1119 

near the articular ends (Fig. 194) ; these may soften and break down 
with abscesses, sinuses, etc., very much after the manner of a tubercu- 
lous inflammation. 

The lesions of the other long bones are essentially the same as of 
the tibia. They are nearly always symmetrical and often multiple. The 
course of syphilitic osteoperiostitis is very chronic, and some permanent 
deformity is the rule, unless cases come very early under treatment. 

When affecting the bones of the cranium the disease usually takes the 
form of a gummatous periostitis, which leads to the formation of large 




v 

Fig. 193. — Syphilitic Osteoperiostitis of the Tibia. Left tibia greatly enlarged; 
\% inches longer than the right, and leg 2 inches larger in circumference; saber-like 
anterior border. Right tibia normal; lesion of long standing. Patient 13 years old. 

nodes. These may remain as permanent deformities, or they may break 
down and suppurate, with necrosis of one or both tallies of the skull. 
This may be followed by inflammation of the dura, the pia. and even of 
the brain itself. 

When the long bones are affected, the symptoms arc pain, tenderness, 
and deformity. These come on very gradually, and often the deformity 
is noticed before either pain or tenderness is sufficiently marked to attracl 
attention. The pain is regularly worse at night, and often fell only at 
that time; it may be mild and occasional, or so severe as virtually to 
prevent sleep. There is tenderness on pressure over the bones affected, 



1120 



THE SPECIFIC INFECTIOUS DISEASES 



the acuteness of which will depend upon the activity of the process. 
When suppuration occurs, it comes very slowly, and never with symptoms 
of acute inflammation. Sinuses usually continue to discharge until a 
sequestrum is exfoliated. The course of the disease is very tedious, and 
the whole duration is usually several years. 









Fig. 194. — Syphilitic Osteoperiostitis of the Left Tibia. Similar lesion to that 
shown in Fig. 193; patient 8 years old. The right tibia is normal. 

When the cranium is affected, there are seen irregular nodes, espe- 
cially upon the frontal and parietal bones. They are from one to two 
inches in diameter, and project from one-eighth to one-fourth of an inch 
above the general outline of the skull. There may be pain, tenderness, 
softening, suppuration, and necrosis, as in the long bones. 

It is rare that disease of the bones of the cranium is due in childhood 
to any other cause than syphilis, and this disease may usually be assumed 
to exist if traumatism can be excluded. The bosses upon the cranium 



HEREDITARY SYPHILIS 1121 

in rickets are always large, smooth, and regular in position, and belong 
to infancy. 

Syphilitic disease of the long bones is recognized by the nocturnal 
pain, the tenderness and peculiar deformity, and by the association of 
other late manifestations of syphilis — i. e., the peculiar notched teeth, 
the interstitial keratitis, the enlarged epitrochlear glands, etc. Tuber- 
culous disease generally affects the articular ends of the bones; syphilis 
nearly always the shaft. The diffuse hyperplasia of the tibia and the 
saber-like deformity of its anterior border are rarely, if ever, due to any 
other cause than syphilis. The deformities of the long bones have in 
some cases a certain resemblance to those due to rickets, but the two con- 
ditions can hardly be confused if a careful examination is made. 

Arthritis. — This may occur in a subacute or even acute form. It is 
most common in the knee, though any of the large joints may be in- 
volved. The lesion is chiefly synovial. The onset may be sudden with 
pain and marked tenderness. Effusion into the joint occurs and there is 
local heat and often a rise in temperature to 101° F. or more. The 
process usually remains limited to one joint and resists obstinately all 
methods of treatment except antis3 r philitic treatment, to which it readily 
yields. 

Lymph Nodes. — They are less frequently affected than in adults. In 
most cases there may be found a moderate degree of enlargement of the 
postcervical and epitrochlear glands, swelling of the latter having con- 
siderable diagnostic value. Under normal conditions these can scarcely 
be felt; but in syphilitic children they may be as large as a pea or a 
small bean ; sometimes two or three of them can be distinguished. Pro- 
vided no local cause for the swelling exists, they should always create 
a suspicion of syphilis. The postcervical glands are frequently affected, 
but are not so diagnostic. The degree of enlargement is rarely great. 
Occasionally there are seen in the neck largo masses of swollen lymph 
glands which resemble tuberculous swellings. They are, however, very 
rare. 

Special Senses. — The most frequent affection of the eye in late syph- 
ilis is interstitial keratitis, the close connection of which with hereditary 
syphilis was first pointed out by Hutchinson. It is often found asso- 
ciated with the typical notched teeth. The diagnostic value of keratitis 
in syphilis is denied by Fournier, who states that, while often syphilitic, 
it is not infrequently due simply to malnutrition. We cannol subscribe 
to this statement. In our experience it is alntosi always due to syphilis. 
Both eyes are usually affected, and in all degrees of severity, from a slighl 
haziness of the cornea to complete opacity. However, with an early diag- 
nosis and prompt treatment, a marked degree of improvement may be 
expected in most cases. 



1122 THE SPECIFIC INFECTIOUS DISEASES 

Chronic otitis may be a result of the acute process seen in early 
infancy. There is nothing peculiar about the inflammation in these 
cases. A form of deafness occurs in older children, which Hutchinson 
states is almost invariably due to syphilis. Its onset is quite sudden, 
without pain. The loss of hearing is apt to be permanent, and if it 
occurs early in childhood it is a cause of deaf -mutism. 

Skin. — The most important of the later manifestations of syphilis 
consists in the formation of subcutaneous gummata. In the early stage 
they are indurated, elastic, of a grayish color, with red borders. Under 
treatment they disappear quite rapidly by absorption ; but when neglected 
they break down, leaving large deep ulcers. These ulcers are quite char- 
acteristic in appearance, but may be confounded with those due to tuber- 
culosis. The syphilitic ulcer has rounded, thickened, indurated borders, 
and a base which is depressed and has the appearance of being scooped 
out. It is sometimes covered by hard crusts and is surrounded by a red 
areola. It leaves a smooth white scar. The most frequent situation 
is upon the face and upper part of the legs or thighs. Tuberculous 
ulcers have usually soft, flat edges, and do not extend so deeply; they 
are more irregular in outline; the cicatrix left is of a purplish color, 
which becomes red and slowly fades ; and tubercle bacilli may be found. 

Nose and Palate. — Disease of these parts generally begins as the 
breaking down of gummatous deposits in the mucous membrane. The 
nose may in consequence be the seat of a protracted fetid discharge 
(ozena) . The disease may take on a destructive form of ulceration which 
is at times phagedenic, and may cause rapid destruction of the nasal car- 
tilages and bones, perforation of the septum, and occasionally of the floor 
of the nasal fossae. There may be necrosis of the turbinated bones, the 
vomer, or the ethmoid. In the most severe forms the nose may be almost 
destroyed in the course of a few weeks. There may be at the same time 
deep ulceration of the soft palate, leading to perforation. In a young 
person this is almost invariably due to syphilis. In many particulars 
these ulcerations of the nose and palate resemble lupus; they are dis- 
tinguished by the rapidity of their progress, syphilis often doing as 
much damage in weeks as is done by lupus in years. 

Other Symptoms. — Syphilitic disease of the larynx and bronchi is 
rare in childhood. The former may give rise to hoarseness or aphonia 
and occasionally to stenosis ; the latter to a chronic cough and asthmatic 
attacks. There are no characteristic symptoms belonging to syphilis 
of the lungs. 

The only visceral changes which aid much in diagnosis are those of 
the liver and spleen. The liver is often enlarged, sometimes to a marked 
degree, and occasionally there is ascites, but very seldom jaundice. 

Enlargement of the spleen is a very frequent symptom — in fact, it is 



HEREDITARY SYPHILIS 1123 

almost constant during active syphilitic disease. It is occasionally so 
swollen as to form an abdominal tumor of considerable size. In one case 
under our observation, in a boy three years old, the spleen extended five 
inches below the free border of the ribs, quite to the crest of the ileum. 
It was associated with moderate enlargement of the liver, as is usually 
the case. 

In addition to the local symptoms of late hereditary syphilis enu- 
merated, there are others of a general character which are quite as im- 
portant. The body is usually undersized; the constitution is delicate, 
and shows but little resistance to all forms of disease; puberty is fre- 
quently delayed, and the development of the breasts and the genital 
organs often imperfect; anemia is usually present, and the skin has a 
sallow appearance. Mentally, many of these children are somewhat de- 
ficient. 

Syphilis of the Nervous System. — This may show itself in a great 
variety of ways. There may be a combination of symptoms giving rise to 
a more or less distinct clinical picture, indicating diffuse involvement 
of one or more parts of the brain or cord, or the lesion may apparently 
be limited to a strikingly small area. 

Paralysis of single nerves, particularly the cranial nerves, is not un- 
common. There may be only failure of one or both pupils to react to 
light, or there may be strabismus. Sudden deafness may occur. There 
may be a gradually developing optic atrophy. 

Mention has been made of syphilis as a cause of hydrocephalus. In 
our experience the association between the two diseases is unusual, but 
many clinicians with large experience emphasize the fact that hydro- 
cephalus may often be due to syphilis. Epilepsy, also, may depend, 
but in our experience very infrequently, upon syphilis. Statistics vary 
much as to the role of syphilis in producing feeblemindedness. Studies 
upon inmates in institutions for the feebleminded in this country have 
shown that not more than two or three per cent have clear clinical evi- 
dences of syphilis, while not more than ten per cent without physical 
symptoms of the disease give a positive Wassermann reaction. This, of 
course, does not indicate that syphilis is is the ten per cent the cause of 
the feeblemindedness. The association of the two conditions may be 
merely accidental. It is probable that the part of syphilis in the produc- 
tion of mental deficiency has been exaggerated. Lesions of the cord due 
to syphilis are distinctly uncommon. 

Juvenile paresis is occasionally seen, but it is rare; before the fifth 
year. There is no doubt of its dependence upon hereditary syphilis. The 
symptoms usually appear shortly before or aboul the time of puberty. 
They are quite characteristic. A child thai has developed in a practically 
normal way gradually begins to lose his ability 1<» do certain things. 



1124 THE SPECIFIC INFECTIOUS DISEASES 

There is loss of memory and a difficulty in speech, which consists in 
dropping a syllable or a whole word. If he has been able to write, the 
capacity to do this is gradually lost. Eventually speech is impossible and 
the intelligence is reduced to a minimum. Walking becomes difficult 
and later almost impossible. The child loses all sense of cleanliness and 
remains in a demented condition often for years until death occurs from 
inanition, bed-sores or from intercurrent disease. There is usually loss 
of reaction of the pupils to light, irregularity of the pupils, and often 
some degree of optic atrophy. The cerebrospinal fluid contains an excess 
of cells and globulin and gives a strongly positive Wassermann reaction. 
The course is slowly but progressively downwards. 

It is at times difficult to differentiate from juvenile paresis a form 
of cerebral syphilis, which in our experience is more common than the 
paretic form. The history often gives valuable aid, showing that the 
child has ever appeared entirely normal. There has usually been, almost 
from the beginning, some, often a marked, degree of mental impairment 
and speech has been slowly and imperfectly acquired. The children are 
oftentimes restless and disobedient. They may have screaming attacks. 
The reflexes may be exaggerated or absent. Attacks of headache and 
vertigo with vomiting are not uncommon. There may be unequal pupils 
or failure to react to light. Some degree of optic atrophy is generally 
present. Hemiplegic attacks may occur in the course of the disease or 
they may appear as the first evidence of cerebral involvement. These 
attacks may occur first on one side and then on the other, and the 
paralysis often improves to a marked degree, even without treatment. 
With this form of cerebral syphilis there is not the same tendency to 
mental and physical deterioration as with paresis. The children may 
live many years in about the same mental condition. Sometimes with 
treatment, especially if it is begun early, considerable improvement oc- 
curs. The cerebrospinal fluid shows in these cases also an excess of cells 
and globulin and always gives a strongly positive Wassermann reaction. 
As is the case with paresis, it is exceedingly difficult to diminish the 
intensity of or to abolish the Wassermann reaction in the spinal fluid by 
antisyphilitic treatment of any kind, no matter how vigorously given or 
how often repeated. 

Tabes may be found in childhood as the result of hereditary syphilis 
but is very uncommon. The symptoms are similar to those of the adult 
form of the disease, but some of them may be absent. The Argyll- 
Robertson pupil is constant, but the patellar reflexes may not be lost 
and Romberg's symptom, may not be marked. Incontinence of urine is 
frequent. The course of the disease is exceedingly slow. It may last for 
fifteen or twenty years or even more. 

Diagnosis. — The diagnosis of early syphilis in most cases is not diffi- 



HEREDITARY SYPHILIS 1125 

cult. The coryza, eruption, labial fissures, mucous patches about the 
anus and genitals, enlarged spleen, and later the general cachexia — all 
unite to form a picture which it is difficult to mistake. In irregular 
cases the diagnosis is easy just in proportion to the number of the fore- 
going symptoms which are present. Special care should be taken not to 
confound the moist papules of simple intertrigo upon the buttocks or 
thighs with those of syphilis. Much assistance may be obtained, espe- 
cially in early cases, from the discovery of the spirochetae in the external 
lesions. This is a means of diagnosis which is too seldom employed. In 
a series of 34 cases, mostly early ones, in the hospital service of one of 
us, there were external lesions in 22, in all but one of which the spiro- 
chetae were demonstrated. The dark field is useful but not essential. 
They can easily be demonstrated by the India ink method. The Wasser- 
mann reaction has the same value as in adults. 

In late syphilis the following symptoms are the most reliable for 
diagnosis : notching of the teeth, falling in of the bridge of the nose, 
interstitial keratitis, deafness not traceable to ordinary otitis, enlarge- 
ment of the spleen and epitrochlear glands, ulceration of the palate or 
nose, the saber-like deformity of the tibia, and nodes upon the tibia or 
cranium. There are often found in older children indefinite symptoms 
in regard to which a suspicion of syphilis exists. For such cases the 
Wassermann test is of very great value. 

It becomes at times important to distinguish hereditary from ac- 
quired syphilis. Visceral lesions in acquired syphilis are not common 
and belong to the late period of the disease ; in the hereditary form they 
are well-nigh constant and occur early, often being present at birth. 
The acute epiphysitis, sometimes accompanied by pseudoparalysis, sel- 
dom if ever occurs in acquired syphilis, though frequent in the hereditary 
form. Symptoms due to defects in development, like the misshapen fin- 
ger-nails, are seen only in hereditary syphilis. The early symptoms ref- 
erable to the mucous membranes and mucocutaneous surfaces — coryza, 
hoarseness, hemorrhages, labial fissures, etc. — so characteristic of he- 
reditary syphilis, have no place in the acquired form, while the single 
primary lesion sometimes found in the acquired form does not exist in 
the hereditary disease. 

The value of Noguchi's cutaneous "luet in" tesi has noi ye1 been finally 
settled. Considerable experience is needed to interpret result-. 

Prognosis. — Generally speaking, the prognosis is worse in infantile 
syphilis than in that of adults. In infancy it is much worse when hered- 
itary than when acquired, for the reason thai often the child who is the 
subject of hereditary syphilis has been affected by the poison from the 
very beginning of his existence, and this has modified his entire de- 
velopment. 



1126 THE SPECIFIC INFECTIOUS DISEASES 

The results of 206 syphilitic pregnancies observed by Julien (Paris) 
were as follows: abortion occurred in 36, stillbirths in 8, and 69 chil- 
dren died soon after birth, making a total mortality of 55 per cent; 
50 Avere living and syphilitic; only 43 living and in good health. Still 
worse were the results in cases observed by Le Pileur : of 154 pregnancies 
in syphilitic women, there were 120 abortions or stillbirths, 26 children 
died soon after birth, and only 8 survived. The statistics of the Found- 
ling Asylum in Moscow for ten years showed that of 2,038 syphilitic in- 
fants the mortality was over 70 per cent. 

Such a mortality as that indicated in the above statistics is seen only 
in institutions where little or no previous treatment has been employed. 
In private practice certainly nothing approaching it occurs. 

In addition to those who die early as the result of syphilitic infection, 
there must be added many whose constitutions are so impaired by syphilis 
that they fall an easy prey in infancy to pneumonia, diarrhea, or other 
forms of acute disease. The remote effects of syphilis in infancy it is 
hard to estimate; it may exert an injurious influence upon the constitu- 
tion in childhood, and even throughout the life of the individual. 

The prognosis in an individual case depends upon the age at which 
the symptoms develop, the time when treatment is begun, upon its thor- 
oughness, and upon the surroundings and mode of nourishment of the 
child. The outlook is better the longer after birth the first symptoms 
appear; it is also very much better in infants who are nursed than in 
those who are artificially fed. 

As compared with syphilis of the adult, relapses are less frequent, 
and when they occur early they are nearly always the result of insufficient 
treatment. If proper treatment is carried out, these severe late symptoms 
are not common ; patients are usually free from all symptoms until six or 
seven years old, or until near the time of puberty — two periods when they 
are likely to develop. We must conclude that treatment persisted in 
only for a short time and not energetic enough to influence in any way 
the Wassermann reaction has, nevertheless, a great influence in prevent- 
ing the further ravages of the disease. We have observed children after 
an interval of several years that had been treated in this unsatisfactory 
way and could find no evidence of the disease but a positive Wassermann 
reaction. It is a fact also that most of the patients that apply for treat- 
ment for late hereditary syphilis have never received any treatment. 

The prognosis is better in the later children of syphilitic parents than 
in the earlier ones, provided infection has preceded the birth of all the 
children. This fact illustrates the general tendency of the syphilitic 
poison to diminish in virulence as time passes, even without treatment. 
The following instance cited by Bertin well illustrates this point: 

In the first pregnancy, the mother aborted with a dead child at the 



HEREDITARY SYPHILIS 1127 

sixth month ; in the second, at the seventh month ; in the third, at seven 
and a half months; in the fourth the child was born at term, and lived 
eighteen days ; in the fifth it lived six weeks ; in the sixth the child lived 
four months, without treatment. 

The prognosis of syphilis of the nervous system should be considered 
by itself. Certain of the manifestations, such as localized paralyses, may 
yield promptly to treatment. It is also reported that many cases of 
syphilitic epilepsy and hydrocephalus have been greatly improved or 
cured. Gummatous lesions usually disappear promptly with appropriate 
treatment as in acquired syphilis. But the lesions of the nervous system 
are usually the result of arterial disease or of meningitis and encephalitis. 
These are very little influenced by treatment. In cases of diffuse involve- 
ment of the brain and in juvenile paresis, we have not seen lasting benefit 
from even the most energetic and long-continued treatment with salvarsan 
or with mercury and iodids. 

Prophylaxis. — Xo infected person should be allowed to marry until 
at least two years have passed after the initial sore, treatment being con- 
tinued meanwhile; nor if there are any active symptoms, no matter how 
long a time has elapsed since infection, nor if the Wassermann reaction is 
positive. 

The mother should be treated during her pregnancy: (1) If she is 
syphilitic, whether the disease was acquired at the time of conception 
or subsequently ; (2) if the father is known to be suffering from syphilis, 
whether the mother has symptoms or not; (3) if the mother has ever 
previously shown signs of syphilis, even if she has had no active symptoms 
for a considerable period. In all these conditions if efficient treatment is 
carried on throughout pregnancy there is a strong probability, but in no 
case a certainty, that the child will escape. The third condition men- 
tioned is the one in which treatment is most likely to be neglected, 
especially if the mother has previously borne a child who was not 
syphilitic. Syphilis, however, shows a strong tendency to reappear and 
become active during pregnancy, even though it has been long quiescent, 
as the following case cited by Diday shows: 

A woman who had lost seven children from syphilis was put under 
treatment during the eighth pregnancy; result — child born healthy, and 
continued so. In the ninth pregnancy treatment was continued with a 
like result; in the tenth pregnancy, no treatment, child syphilitic, dying 
when six months old; in the eleventh pregnancy, treatment repeated, 
child healthy. 

The danger of infection during labor is slight. As the greatest 
danger of infecting a child after birth is from his parents or a wet-nurse, 
syphilitic parents should lie duly warned of the danger to their children, 
and especially should be cautioned against kissing them or sleeping in 



1128 THE SPECIFIC INFECTIOUS DISEASES 

the same bed with them. The utmost care should be exercised to pre- 
vent a healthy child from being infected by a syphilitic nurse. A nurse 
should never be accepted without a thorough physical examination, no 
matter how clear a history may be given. As a syphilitic child in the 
household may be the means of infecting other children, the same precau- 
tions should be taken as in the case of other contagious diseases. The 
chief danger to other children comes from kissing or from using bottles, 
spoons, or cups which have been infected; as the syphilitic infant is 
chiefly dangerous on account of the lesions in the mouth. Trouble most 
frequently occurs because of ignorance regarding the nature of the dis- 
ease. It is possible for a syphilitic child to nurse a healthy woman 
without communicating syphilis, if the child's mouth contains no lesions 
and the nipple not allowed to become fissured; but it is an experiment 
which should never be tried. 

Treatment. — This should always be begun as soon as the first posi- 
tive symptoms of syphilis appear. In certain circumstances it may be 
advisable not to wait for symptoms; as, for example, when both parents 
have recently suffered from active symptoms, when previous children 
have died soon after birth, or when, with marked symptoms in the par- 
ents, the child exhibits the cachexia of syphilis, but no definite local 
symptoms. Such anticipatory treatment need not be continued after a 
negative Wassermann reaction is obtained. It should be remembered, 
however, that even a syphilitic infant may give a negative Wassermann 
reaction for the first two or three weeks of life. 

The indirect treatment, designed to reach the child through the 
mother's milk, has fallen into deserved disuse, as it is very uncertain 
and altogether unsatisfactory. 

The two drugs most useful in treatment are mercury and salvarsan. 
Mercury is as much a specific for hereditary as for acquired syphilis. 
There are many ways of introducing it into the system — by inunctions, 
by mouth, by fumigations, baths, or hypodermically. In most cases, in- 
unction is the manner to be preferred with children. Mercurial ointment 
in doses of from ten to twenty grains, depending upon the size of the 
child, diluted with an equal amount of vaseline may be rubbed into the 
abdomen, axillae, or the inner surface of the thighs. It is advisable to 
change the place of inunction from time to time and if this is done it is 
extremely rare that erythema is produced. It may advantageously be 
placed, with small infants, upon the inner surface of an abdominal binder. 
If for any reason inunctions are objectionable, as they may be when the 
family are to be kept in ignorance, either the gray powder or the bichlorid 
may be given by month. The usual dose of the gray powder is gr. y 2 , 
three times a day, and that of the bichlorid, gr. 1-60 three times a day, 
always well diluted. It is rare that larger doses are advisable. Calomel 






HEREDITARY SYPHILIS 1129 

in doses of 1-10 gr. four times a day is oftentimes a rapid method of 
bringing the system under the influence of mercury. Other methods of 
administration and other preparations offer no advantages and have 
some very obvious disadvantages. The duration of mercurial treatment 
should be at least one year. The doses during the last six months may 
be reduced to one half or one third of those employed while active symp- 
toms were present. It is well to repeat two or three months of mercurial 
treatment during the second and third years, even if no symptoms are 
present. Treatment, should always be employed longer than a year if 
symptoms exist. It is often better not to give the mercury continuously, 
but with short periods of intermission. 

Salvarsan is quite as efficacious in infants as in older patients. Single 
doses of salvarsan do not cure syphilis and several doses may not do so. 
A repetition is always necessary and the best results are obtained when 
salvarsan is combined with the mercurial treatment. In such circum- 
stances, it is wise to omit the mercury for a few days before and after 
the injection of salvarsan. The intravenous method of administration 
of salvarsan is altogether to be preferred on account of its irritating 
effects when injected into the tissues. The usual dose is .05 gram for 
very young infants and 0.1 gram for those who are five or six months 
old. More exactly it may be calculated as 0.01 gram for each kilogram 
(.005 per pound) of body weight. With infants, the injection may be 
made into a vein of the scalp or the external jugular vein. No dissec- 
tion is necessary but care should be taken that none of the injected fluid 
is allowed to escape into the surrounding tissue, otherwise sloughing 
may result. Neosalvarsan has the advantages of being more readily 
prepared, much less irritating in its effect and consequently much less 
likely to cause necrosis if any escapes into the tissues. It is, how- 
ever, less active and the dose should be one and one-half times that of 
salvarsan. The usual doses of neosalvarsan required by infants are 
readily given in 5 c.c. of freshly distilled water. The intravenous use 
of this preparation is greatly to be preferred. ]f, however, for any 
reason tin's is not practicable, neosalvarsan may be given intramuscularly, 
dissolved in some bland oil such as benzoinol. Salvarsan should not be so 
given. 

Injections of salvarsan should not be made more frequently than 
once in two weeks, usually repeated four or five times and controlled by 
the Wassermann reaction. It is uncommon for a negative reaction to be 
obtained after less than three injections; we have used as many as eight 
and have found at times the reaction persistently positive. 

The iodid of potassium may be used in combination with mercury 
whenever such lesions exist as are classed among adults as tertiary. This 
includes all the late manifestations and the earlier ones whenever the 



1130 THE SPECIFIC INFECTIOUS DISEASES 

bones or viscera are affected. The iodid is usually well borne by chil- 
dren and may be given in almost any desired dosage. In infancy, not 
more than gr. xx daily are required, but in older children one or two 
drams daily may be given, always largely diluted. 

Syphilis of the nervous system is often but slightly affected by 
treatment, as has been mentioned previously. The symptoms of sharply 
localized disease, including the gummatous lesions, are usually promptly 
affected, but diffuse cerebrospinal syphilis, including paresis and tabes, is 
hardly benefited at all. The Wassermann reaction in the blood may some- 
times be made negative, but the Wassermann reaction of the cerebro- 
spinal fluid remains positive and the symptoms are in almost all in- 
stances entirely unaffected. 

The general treatment of syphilis is important and should not be 
neglected. After specific treatment has been carried on for a time, 
particularly if rapidly pushed, the child often becomes anemic and 
suffers greatly from malnutrition. In such circumstances, it is usu- 
ally wise to discontinue mercury altogether for a time, or at least to 
reduce the dose very much. Such a change is frequently found to act 
most beneficially. 

Local Treatment. — Ulcerative lesions of the skin require cleanliness, 
dusting with calomel or iodoform, or bathing with the black wash. 
Mucous patches should be dusted with equal parts of calomel and bis- 
muth. Fissures and ulcers of the mucous membranes should be treated 
by nitrate of silver. Phagedenic ulcers of the palate or nose should 
be cauterized with nitric acid or the acid nitrate of mercury. The late 
syphilitic ulcers of the skin, due to the breaking down of gummata, 
should be treated aseptically. 



CHAPTER XII 
INFLUENZA 

In 1892 a bacillus was described by Pfeiffer which he believed to be 
the cause of epidemic influenza or what is commonly known as the grippe. 
It seems evident by the studies of the last half dozen years that this or- 
ganism is not the cause of the grippe, although it is a pathogenic organ- 
ism of considerable importance in respiratory diseases, and is associated 
with a pretty definite group of clinical symptoms. In this chapter we 
shall include under the term Influenza only the disease or diseases due 
to Pfeiffer's bacillus. 

Etiology. — Pfeiffer's bacillus, or the influenza bacillus as it is known 



INFLUENZA 1131 

in literature, is chiefly found in the secretions of the lower respiratory 
tract; less often in those of the upper tract — the rhinopharynx and dis- 
charges from the ears. As it usually occurs, it has been shown by Woll- 
stein to be an organism of low virulence. It produces few immune 
bodies and consequently complement fixation cannot be demonstrated in 
the serum of these patients. It does not agglutinate except in very low 
dilutions. Xo immunity is developed from such attacks and hence pa- 
tients are continually liable to recurrent influenza infection. Like the 
pneuinococcus, Pfeifler^s bacillus may be present in the respiratory secre- 
tions without producing any symptoms whatever. It may be of no sig- 
nificance. At times very virulent strains of the influenza bacillus are met 
with. These produce antibodies and cause immunity ; but unfortunately 
because of their virulence the patient is likely to be overpowered before 
this has occurred. The organism may quickly find its way from the res- 
piratory tract into the blood stream, producing an intense septicemia and 
leading to the development of a severe form of pneumonia, to cerebro- 
spinal meningitis, and rarely to inflammation of the large joints. Pfeif- 
fer's bacillus belongs to the hemoglobinophilic group, growing only on a 
medium containing hemoglobin. It can be demonstrated in the sputum 
with certainty only by cultivation, smears being entirely unsatisfactory. 
In acute cases it may disappear very early; but in protracted cases its 
presence can often be demonstrated for weeks or even months. In the 
respiratory inflammations in which the organism occurs, although it may 
be found in pure culture, it is usually associated with the pneumococcus or 
the staphylococcus aureus, less frequently with the streptococcus. In rou- 
tine cultures made from the sputum in acute respiratory infections in 
the winter and spring in the Babies' Hospital during a period of six years 
the influenza bacillus was found in different years in from 28 to 42 per 
cent of the cases. 

Influenza may be ranked among moderately contagious diseases. It 
is rather more communicable than pneumococcus infections, but much 
less so than epidemic catarrh or the grippe. The influenza bacillus is 
regularly found in New York in the cold season, beginning early in 
November, but most years is not frequently found till after January. It 
usually disappears completely about the end of May with the advent of 
very warm weather. Its prevalence in the winter and spring of sonic 
seasons is so great that it may often be said to he epidemic. All ,i 
are liable to the disease, infants especially so. 

lesions. — The influenza bacillus is much less frequently associated 
with the inflammations of the upper than the lower respiratory tract. It 
is found in comparatively few of the cases of acute rhinopharyngitis, in 
the severe inflammations which invade the antrum, the frontal or ethmoi- 
dal sinus or the middle ear. It Is much more frequently associated with 



1132 



THE SPECIFIC INFECTIOUS DISEASES 



inflammations of the trachea, bronchi, and kings. There are no charac- 
teristic lesions of influenza. Those found in the respiratory tract differ 
little from the same inflammations when due to other organisms. The 
pneumonia is nearly always of the bronchopneumonia type. In certain 
cases resolution is much delayed or is incomplete and the inflammation 
may then develop into a chronic interstitial type which may continue 
indefinitely, with the later development of fibrosis in the lung of con- 
siderable extent with bronchiectasis, etc. 




Pig. 195. — Temperature Chart of Uncomplicated Influenza. Infant fourteen 
months old. No local signs of disease; repeated blood examinations for malaria 
negative; the wide fluctuations of the temperature independent of therapeutic meas- 
ures. Prompt cessation of fever on removal from the city. 



Symptoms, — The symptoms of influenza are in part clue to the gen- 
eral infection and in part to the local inflammations which are excited. 
These may be regarded either in the light of manifestations or possibly 
as complications. The clinical manifestations of influenza are numerous 
and often exceedingly puzzling in diagnosis. Those most frequently met 
with are the following: 

1. There may be only symptoms of a general infection of moderate 
severity, often with a high temperature but with few or no respiratory 
symptoms. 

2. There are cases with symptoms of mild respiratory infections — 
bronchitis, otitis, etc. — or others with severe bronchitis or bronchopneu- 



INFLUENZA 



1133 



monia which present little unusual in their symptoms except quite ex- 
traordinary fluctuations of temperature. 

3. A protracted form of bronchopneumonia or recurring attacks of 
acute bronchopneumonia with incomplete resolution, often mistaken for 
tuberculosis. 

4. A protracted mild respiratory catarrh with little fever but with 
a paroxysmal cough which is almost indistinguishable from whooping- 
cough. 

5. An especially severe form of infection with general blood infec- 
tion often terminating in meningitis. 

The chart (Fig. 195) well illus- 
trates the first group of cases. There 
are often no local symptoms of im- 
portance to be found on the most 
careful examination; there is a high 
and widely-fluctuating temperature 
which is quite out of proportion to 
the other symptoms. The child does 
not appear to be seriously ill, yet the 
height of the temperature and its 
wide fluctuations are most alarming. 
Sometimes at the height of the fever 
there may be marked nervous symp- 
toms — irritability, hyperesthesia, 
rigidity, stupor, etc., strongly sug- 
gestive of cerebrospinal meningitis; 
but with the fall in the temperature 
all these symptoms pass off in a few 
hours. In most of the cases the 
only symptoms present are such as 

accompany high temperature from any cause. In some there is an acute 
erythematous blush of the fauces and in many there is a slight cough. 
Often such a temperature as that shown in the chart may continue for 
several days, subside without treatment, and all symptoms recur after 
an interval of a few days or one or two weeks; finally a small area of 
pneumonia may be discovered, or perhaps otitis may develop as a Later 
complication. The improvement in Bymptoms by change in climate is 
sometimes most surprising and occasionally an equally abrupt ending of 
the attack may occur without it. More frequently, however, the symp- 
toms subside gradually. Malaria or some hidden focus of suppuration are 
most frequently diagnosticated. 

The cases of pneumonia associated with influenza are sometimes 




Fig. 196. — Acute Bronchopneumonia, 
Abortive Type, Complicating In- 
fluenza in an Infant Six Months 
Old. The entire left lung posteriorly 
was involved. 



such brief duration as to be classed as abortive (Fig. L96). 



of 
l'lic attack 



1134 



THE SPECIFIC INFECTIOUS DISEASES 



begins like an ordinary pneumonia of perhaps more than usual severity; 
but after two or three days, generally before signs of complete consolida- 
tion have appeared, a rapid subsidence of symptoms and signs takes place 
with a speedy convalescence. In other cases of pneumonia more often 
seen the physical signs and general symptoms do not differ essentially 
from those of an ordinary pneumonia, but the temperature shows the 
same tendency to high and irregular fluctuations without evident reason, 
similar to those seen in the first group considered (see Fig. 62, Chapter 
on Pneumonia). 

Influenza complicated by otitis often presents a most difficult problem 
in diagnosis. The early part of the attack may be with general symp- 



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Fig. 197. — Influenza-bronchitis; Double Otitis; Late Bronchopneumonia; Au- 
topsy. Infant, nine months old, admitted with influenza-bronchitis; double para- 
centesis fourth day, repeated on tenth day; the left ear opened again on twelfth and 
twenty-fourth days. The only signs in the chest were those of bronchitis until the 
eighteenth day, then bronchopneumonia which persisted until death. On account 
of the wide fluctuations in temperature from the eighth to the eighteenth day, mas- 
toiditis and sinus thrombosis suspected. Operation not permitted, partly because 
of the child's poor condition, but chiefly because the bacillus influenzae was con- 
stantly present in the bronchial secretion and this was regarded as a sufficient ex- 
planation of the temperature. Autopsy. — Moderate bronchopneumonia; cultures 
from the lungs showed the influenza bacillus and pneumococcus. Careful examina- 
tion of the mastoid and sinus showed no trace of disease. 



toms which are not particularly characteristic. Otitis develops after a 
time as a complication; the ears are opened, the temperature does not 
subside, however, but assumes the widely fluctuating character seen in 
many cases of influenza. It is often assumed that the continuance of the 
temperature is due to some grave condition associated with the otitis 
— mastoiditis, sinus thrombosis, etc. — and serious operations have often 
been performed in these circumstances; whereas the fever was simply 
a manifestation of the general influenza infection upon which the para- 
centesis has of course had no effect (Fig. 197). Intercurrent attacks 
of influenza occurring in surgical cases with few or no respiratory symp- 
toms may also be very puzzling. 

The most characteristic forms of pneumonia accompanying influenza 
are the cases which in the early part of the attack may show little that 



INFLUENZA 1135 

is unusual except the very irregular temperature curve. The signs are 
like those of ordinary bronchopneumonia, often with a lobar type of con- 
solidation. The course is a very protracted one. The signs clear up very 
slowly and imperfectly. The children get better, but they do not get 
well. One attack often succeeds another, separated sometimes by an 
interval of onty a few days, and sometimes of several weeks, and so a 
patient may go on for the greater part of a season. Tuberculosis is 
usually suspected, and no doubt it is frequently the explanation of similar 
symptoms. But we see many cases which are not tuberculous; the von 
Pirquet test is negative and tubercle bacilli are not found in the spu- 
tum, but the influenza bacillus is often regularly found for months. 
The persistence of the organism in the lungs and smaller bronchi is ex- 
ceeded only by that of the tubercle bacillus. Many of these cases re- 
cover slowly and recover completely so far as can be determined clinically. 
There are some, however, which go on to chronic interstitial pneumonia 
and a few which develop bronchiectasis. 

Influenza may be accompanied by a paroxysmal cough which is hard 
to distinguish from pertussis. There is a mild degree of laryngotracheitis 
or tracheobronchitis with few constitutional symptoms. Such a cough we 
have seen continue for from four to six weeks with paroxysms so severe 
as to excite vomiting. We have observed it in families of children who 
had previously had pertussis. Borders bacillus could not be discovered in 
the sputum but the influenza bacillus was present. There was no lympho- 
cytosis but only a moderate polymorphonuclear leucocytosis. We believe 
that many of the reported instances of second attacks of pertussis are 
of this nature. 

The very virulent forms of influenza are not common. It is usually 
only on account of the pulmonary complications that the attacks are 
serious. Every now and then, however, one encounters the especially 
severe type. The early symptoms often are not grave and for two or 
three days the patient's condition may excite no apprehension, when 
there develops, often quite rapidly, a state of profound general septice- 
mia with great prostration and a severe pneumonia; or there are Been 
convulsions, drowsiness and stupor, hyperesthesia and rigidity; in short 
the symptoms of an acute meningitis which in our experience has been 
invariably fatal. The blood cultures in these cases regularly show the 
presence of the influenza bacillus. 

Suppuration in the large joints we have in a few instances seen in 
influenza, in which this organism was found in the \)\\< in pure culture. 
Usually this occurs as a late symptom. We have in one case seen it as 
the first definite local symptom. A boy of eighl months after five days 
of general febrile symptoms < U*\ « -i< >| »«•< I swelling of an elbow and ankle. 
When first seen one week later there was general prostration, and the in- 



1136 THE SPECIFIC INFECTIOUS DISEASES 

fluenza bacillus was gri wn from pus aspirated from both joints. The fol- 
lowing day convulsions occurred and the cerebrospinal fluid was turbid 
and contained the same organism. It was also found in the blood culture. 
Death from meningitis occurred three days later and at autopsy the 
influenza bacillus was obtained from brain, lungs, and blood. This 
proved to be one of the most virulent strains of the influenza bacillus 
ever tested in the hospital laboratory. 

The influenza bacillus is associated chiefly with inflammations of 
the lower respiratory tract; in which respect it closely resembles the 
pneumococcus. The two organisms are often associated in inflamma- 
tions of the lungs and bronchi. It has also the same tendency as the 
pneumococcus when in virulent form to excite a general septicemia, 
cerebrospinal meningitis and occasionally joint suppuration. It differs 
from it in being much less frequently associated with inflammations of 
the upper respiratory tract, and in occurring almost solely in the cold 
season, while pneumococcus infections prevail throughout the entire 
year. 

Gastro-intestinal symptoms associated with the influenza bacillus we 
have not seen other than those that may occur with any form of acute 
febrile illness. 

Complications and Sequelae. — The most frequent complications are 
bronchitis, pneumonia, otitis, and adenitis. In most of the cases with 
high temperature the urine contains albumin, and acute nephritis is oc- 
casionally seen. We have seen three cases of hemorrhagic nephritis in a 
single season. All recovered promptly. In one case the influenza bacillus 
was obtained from the urine by culture. One of the most frequent 
sequelae is anemia; this may be severe. Following the inflammation 
of the mucous membranes, there may be chronic enlargement of the 
cervical lymph glands. Attacks of influenza bear the same relation to 
the development of tuberculosis as do those of measles. 

Convalescence after influenza is often very slow, and it may be months 
before the full effects of a severe attack have disappeared. For a long 
time the mucous membranes are in an extremely sensitive condition. 
Relapses are often brought about by slight exposure before the .symptoms 
have quite disappeared. 

Diagnosis. — The ordinary head colds even when severe and epidemic 
are very rarely due to influenza infection. The features which distinguish 
influenza infections of the respiratory tract from those due to other causes 
are, the peculiar range of temperature, the tendency to chronicity, to re- 
lapses, and to recurrences. A very high and widely-fluctuating tempera- 
ture accompanied by few constitutional symptoms in the winter season is 
always suggestive. Influenza can be diagnosticated with certainty only 
by cultures which should be made upon blood agar. These should be 



INFLUENZA 1137 

made from the bronchial secretion which is obtained as in cases of 
tuberculosis (q. v.). Cultures from the pharyngeal secretion are not to 
be depended upon. It is somewhat difficult to obtain the organism from 
the bronchial secretion and repeated examinations are usually necessary. 
In some typical cases we have been unable to find it at all during life, 
though it was found in the lungs at autopsy. Influenza may be con- 
founded with malaria or cerebrospinal meningitis; from both of these 
it is distinguished by the methods of diagnosis used to identify these dis- 
eases. In the absence of cultures the diagnosis in many cases must be 
made by exclusion. 

Prognosis. — Uncomplicated cases are seldom fatal, even in infants. 
Though the temperature is very high, recovery may be predicted as long 
as there is no evidence of important complications. The prognosis of 
the pneumonia of influenza is rather worse than that of simple broncho- 
pneumonia. In a word, influenza is serious when there are pulmonary 
complications, but rarely otherwise, except in its virulent form, which, 
however, is infrequent. In this, general blood infection and meningitis 
are likely to occur. 

Treatment. — The communicability of the disease makes it desirable 
that cases of influenza should be isolated whenever practicable, and par- 
ticularly that delicate children, or those prone to pulmonary disease, 
should not be exposed. As there is no specific for influenza, the treat- 
ment is symptomatic and conducted along the same general lines as in 
other respiratory infections. The temperature rarely calls for anti- 
pyretic measures ; for, although very high at times, there is very rarely a 
sustained high temperature. In our experience patients with influenza 
infections are not benefited by very cold air, but on the contrary are not 
infrequently made worse by it. Fresh air is, however, indispensable in 
the treatment of these cases, but at a moderate temperature, i. e., 60° to 
65° F. The cough which so often persists after influenza is best con- 
trolled by cod-liver oil and creosote, used as after acute bronchitis. With 
persistent bronchitis which resists ordinary remedies, a patient should 
be sent to a warm, dry climate. 

The complications of influenza are to be treated as they arise, in 
the same manner as when they occur under other conditions. Especial 
care should be exercised to avoid exposure during convalescence. One 
should be particularly anxious about patients who have a strong ten- 
dency to tuberculosis, and such cases should be watched with the greatest 
care. In prolonged or constantly recurring attacks nothing is of much 
avail except a removal to a warm climate. II' tins is impossible, a 
young or delicate child should be kept indoors during the cold season, 
but frequently moved from one apartment to another. 



1138 THE SPECIFIC INFECTIOUS DISEASES 



EPIDEMIC CATARRH— LA GRIPPE 

To this disease the term Influenza has often been given. With our 
present knowledge it seems to us best to restrict the latter term to the 
disease or diseases just described with which Pfeiffer's bacillus is asso- 
ciated, instead of using it as a general name to cover contagious epidemic 
catarrh. Pfeiffer's bacillus was originally put forward as the cause of 
epidemic catarrh. Studies of the last few years have made this extremely 
doubtful. It is evident, however, that it is found in a certain proportion 
of cases; but it seems to play the role rather of an associated organism, 
exactly as, under the same circumstances, do the pneumococcus and the 
staphylococcus. But all these organisms are frequently found when no 
epidemic exists. The final solution of this question must wait on the 
discovery of the actual cause of the grippe. Meanwhile, there are many 
important reasons for believing that Pfeiffer's bacillus is not its cause: 

(1) The highly contagious character of the disease, in which respect 
it is comparable to measles. The disease due to Pfeiffer's bacillus is only 
moderately communicable. (2) When the grippe is prevailing epidem- 
ically, Pfeiffer's bacillus is found in only a small proportion of the cases ; 
and, per contra, Pfeiffer's bacillus is often found in groups of cases when 
the grippe is not prevalent. ( 3 ) The most striking clinical symptom of the 
disease induced by Pfeiffer's bacillus is a very high temperature without 
other general or local symptoms of corresponding severity; while in the 
grippe exactly the opposite is often the case, i. e., severe general symptoms 
with only a moderate elevation of temperature. (4) The intense general 
prostration, especially symptoms relating to the heart and nervous system, 
so common in the grippe, are not found in the disease due to Pfeiffer's 
bacillus, except in those rare cases of bacteriemia and meningitis. (5) 
Although a prolonged convalescence due to general prostration is not un- 
common, the grippe is usually a short acute infection with little tendency 
to become protracted as are the inflammations due to Pfeiffer's bacillus. 
(6) With either form of infection any part of the respiratory tract may 
be involved in inflammation; but it is characteristic of the grippe that 
it is so often complicated by inflammations of the upper respiratory 
tract — rhinopharyngitis with extension to the adjacent sinuses, otitis, 
mastoiditis, adenitis, etc. — complications which are relatively infrequent 
with infections due to Pfeiffer's bacillus, whose complications are rather 
those of the lower respiratory tract — bronchitis and bronchopneumonia. 

Clinically the grippe is manifested in children as in adults by two 
main groups of symptoms. In one there are quite marked symptoms of 
general prostration, chilly sensations, general aching pains in the muscles 
and sometimes in the joints, with only a moderate elevation of tempera- 



EPIDEMIC CATARRH 1139 

tine — 101° to 103° F. A few respiratory symptoms are usually pres- 
ent, but in most cases there is only a moderate cough and perhaps 
coarse rales in the chest. In infants and young children gastro-intestinal 
symptoms are frequently seen accompanying these symptoms. There 
may be vomiting or acute diarrhea or marked indigestion with quite a 
prolonged loss in weight without either vomiting or diarrhea. 

In the second group of cases the respiratory symptoms are especially 
pronounced. In many these are only of the upper respiratory tract; 
there is a severe inflammation of the rhinopharynx, with sneezing, copious 
discharge from nose and eyes, followed by the development of hoarseness 
and cough. The inflammation does not extend beyond the trachea or 
possibly the larger bronchi. The chief complications of these cases are 
adenitis, otitis frequently followed by mastoiditis, extension from the nose 
to the neighboring sinuses, etc. These cases seldom have high tempera- 
ture except when complicated. In others the temperature is higher and 
acute bronchitis or bronchopneumonia develops early. Although at the 
onset the pneumonia often seems particularly severe, it is not infrequently 
of short duration, resolution taking place before complete consolidation 
of the lungs has occurred. In other cases the type of pneumonia is of 
special severity, spreads rapidly, usually with a fatal outcome. 

The treatment of the grippe is the treatment of its special symptoms 
and complications, which should be managed along the same general 
lines as when these occur under other conditions. 



CHAPTER XIII 
MALARIA 

Malaria is an infectious disease due to the presence in the blood of 
a specific organism often called the plasmodium, but more exactly the 
hematocytozoon malariae. It manifests itself in children by the ordinary 
acute febrile attacks which are seen in adults and by chronic malarial 
poisoning. Both of these forms may present certain peculiar symptoms 
dependent upon the 'age of the patient. 

Etiology. — The malarial organism was discovered by Laveran in 
1881; it is a parasite of the blood and belongs to the group of protozoa. 
It is now well established that the parasite enters the blood through the 
bite of certain forms of mosquito, those belonging to the genus A nopheles, 
and probably in do other way. For this knowledge we nw indebted 
chiefly to the work of Ronald Ross, in India, in 1897. For a general 



1140 THE SPECIFIC INFECTIOUS DISEASES 

discussion of the malarial parasite, its methods of staining, etc., the 
reader is referred to works on clinical medicine. 

Malaria affects all ages, even the newly-born infant. We must accept 
with some allowance the statements made by the older writers upon the 
subject of intra-uterine infection, but in the following case reported by 
Crandall, there seems little doubt that the disease was contracted in 
utero : For ten days before delivery the mother had suffered from a ter- 
tian intermittent of moderate severity. Eighteen hours after birth the 
child was noticed to have cold hands and feet, blue lips and nails, and 
a pinched face. These symptoms lasted about half an hour and were 
followed by a distinct fever. Upon the following day the paroxysm was 
repeated. Examination of the blood of the mother and the child revealed 
the malarial organisms in both cases. 

Malaria is more frequently overlooked in young children than in later 
life, from the fact that its forms are more irregular, and this has led to 
the belief that young children are less liable than adults to the disease. 
We believe, however, the opposite to be the case. In a large number of in- 
stances where families have been exposed to malarial poisoning we have 
noted that the young children were frequently the first to show the 
symptoms of the disease. 

Malaria is an endemic disease prevailing in certain localities. Exact 
knowledge regarding the mode of infection has cleared up many obscure 
points in its etiology. The role of the mosquito explains the greater 
liability to contract malaria after sunset and during the night, the 
danger from stagnant ponds and pools of water, the peculiar suscepti- 
bility of infants and young children, and the greater frequency of the 
disease in the spring and summer. Malarial attacks may, however, occur 
at any season, since the organism may be latent in the body for an 
indefinite time; how long it is impossible to say, but there seems to be 
conclusive proof that it may be for many months. Attacks of malaria 
very often occur when the general health has been reduced by some 
other cause, particularly by disturbances of digestion. 

Lesions. — Opportunities for a study of the peculiarities of the lesions 
of malaria in children are infrequent, especially in New York, as fatal 
cases are extremely rare. We have seen but two. As observed by others, 
the lesions do not differ in any marked way from those of the adult 
form of the disease. The most important changes are the destruc- 
tion of the red corpuscles of the blood, enlargement, and in chronic 
cases hyperplasia with pigmentation of the spleen; less frequently pig- 
mentation of the liver, kidneys, and brain. Pneumonia and gastro- 
enteritis are occasional complications. 

Symptoms. — The clinical forms of malarial fever in children from six 
to ten years old, do not differ essentially from the same disease in adults. 



MALARIA 



1141 



Both tertian (Fig. 199) and estivo-autumnal (Fig. 200) attacks occur 
with considerable frequency, the former being the type most often seen. 
Double tertian infection (Fig. 198) is not uncommon but along the 
middle Atlantic coast the quartan type, unless imported, is unknown. 
The stages of the paroxysm are generally well marked. The cold stage 
begins with a chill or vomiting, with headache, lassitude, and general 



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Fig. 198. — Typical Malarial Temperature, Double Tertian Type, in a Boy Sin: 
Years Old. Each paroxysm preceded by a chill. It will be noticed that, the tem- 
perature rose higher with each succeeding paroxysm; X marks the time when quinin 
was begun. 



pains. The hot stage is usually characterized by a higher temperature 
than in adults, and this is followed by the sweating stage, which is gen- 
erally marked. The paroxysm may be repeated every other day or every 
day, depending upon whether there is a single or double fcerl ian infecl ion, 
until controlled by qiiiniu. Less frequently there is an estivo-autumnal 
infection and the fever is remittent from (In; beginning and (he con- 
stitutional symptoms arc of greater severity. In this form there is 



1142 



THE SPECIFIC INFECTIOUS DISEASES 



marked prostration, the tongue is thickly coated, there are often tender- 
ness and pain in the region of the liver, and occasionally there is slight 
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In infants and very yonng children peculiar types of malaria are 
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Fig. 199. — Typical Malarial Temperature, Tertian Type, in a Boy Five Years Old. 
Onset with vomiting and drowsiness, but no chill. This was an anticipating tertian, 
the first paroxysm occurring at 3 p.m., the second at 12 m., the third at 10 a.m.; X 
marks the time when quinin was begun. 



form of intermittent (Fig. 200). The onset is usually abrupt with 
vomiting, a well-marked chill being rare. Malarial chills are not often 
witnessed in children under five years old. They are replaced in infants 
by cold hands and feet, blue lips and nails, sometimes slight general 
cyanosis, pallor, drowsiness, and prostration. Vomiting has been present 
in two-thirds of our own cases. Several times we have seen a malarial 
attack ushered in by convulsions. 

The fever is relatively higher than in adults, rising rapidly to 104° 
or 105° F., occasionally to 106° or 106.5° F. This continues from four 



MALARIA 



1143 



to twelve hours and gradually falls, usually to normal. The other con- 
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stage is only slightly marked and is often absent altogether. With the 
fall in the temperature there is a gradual subsidence of all the other 
symptoms of the febrile stage. 

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Fig. 200. — An Irregular Malarial Temperature (due to Estivo-Autumnal Infec- 
tion) in a Child Nine Months Old. The paroxysm on the fourth day was accom- 
panied by an attack of acute pulmonary congestion which came near being fatal; 
X marks the time when quinin was begun. Although the course of the temperature 
is irregular, it touched the normal line both on the second and fourth days. 



hours or even for a day, when the second paroxysm occurs. Tliis is 
generally not so well marked as the first one, the third may be even 
less so, and the case may resemble more and more one of continuous 
fever with wide oscillations in the temperature. In sonic cases it is 
remittent at first and later becomes intermittent, but it is very rare 
in any circumstances that the temperature docs not touch the normal 
point at some time in the twenty-four hours. 

Enlargement of the spleen is present in the great majority of cases, 
and usually to a sufficient degree to be readily appreciated by examina- 
tion. The most satisfactory method of examination ie by palpation. 



1144 THE SPECIFIC INFECTIOUS DISEASES 

A spleen which can be easily felt below the ribs (except in the rare 
cases in which the organ is displaced downward by some condition in 
the thorax) is enlarged. When it is not sufficiently enlarged to be 
readily felt by a practiced observer under favorable conditions for ex- 
amination, it is not large enough to be of any diagnostic importance. 
None of the other symptoms occurring in malarial fever are character- 
istic ; they are quite similar to those which are seen in almost all febrile 
attacks. They are anorexia, coated tongue, constipation, and rest- 
lessness. 

Masked or Irregular Forms of Malaria. — These are quite frequent in 
young children, and are due to the presence of certain special or uncom- 
mon symptoms which may readily lead to a mistake in diagnosis. They 
are more often seen than cases of true malarial cachexia. 

Among the most frequent of the irregular forms are those relating 
to the nervous system. Headache is exceedingly common and is usually 
frontal. When severe and associated, with continuous drowsiness, vomit- 
ing, and constipation, it may lead to a strong suspicion of tuberculous 
meningitis. Vertigo is not a frequent symptom, but it is sometimes very 
prominent. Pains in various parts of the body are very common. A 
sharp, severe pain at the epigastrium is frequent at the beginning of a 
paroxysm. It is often associated with tenderness, but has no relation 
to meals. Less frequently, pain is localized in the region of the spleen 
or liver. Aching or dragging pains in the muscles of the lower ex- 
tremities are frequent symptoms during acute attacks, but may be of 
short duration, disappearing with the fever. The pain is accompanied 
by tenderness of the muscles and nerve trunks, and by loss of power, 
which is usually partial. 

Accompanying the paroxysm of malaria there is occasionally seen, 
more often in infants than in older children, acute pulmonary congestion 
(Fig. 200), which may give rise to obscure and often very alarming 
symptoms. There is an acute onset with vomiting and prostration, high 
temperature, cough, rapid respiration, and often slight cyanosis. On 
examination of the chest there is found feeble or rude respiration over 
one lung, or over both lungs behind, and sometimes coarse moist rales; 
these signs and symptoms may disappear in the course of a few hours 
with the fall in temperature, to return with the next paroxysm, or if 
quinin is given they may disappear entirely. 1 This group of symptoms 

a The following case is a good example of this condition in its more severe 
form, and illustrates the difficulties in the diagnosis of malaria in infancy: A 
fairly nourished child, nine months old, who had been under observation in an 
institution for two weeks, was suddenly taken with vomiting and fever (Fig. 
200). A cathartic was followed by a large undigested stool, and as the tem- 
perature then fell to normal, the attack was regarded as one of indigestion. On 



MALARIA 1145 

has sometimes led to the mistaken opinion that the disease was pneu- 
monia, which had been aborted by the administration of quinin. 

Subacute or Chronic Forms of Malaria. — The most constant symp- 
toms are anemia, enlargement of the spleen, and slight fever. The 
anemia is usually marked, often being extreme. The enlargement of the 
spleen is distinct, easily made out by palpation, and sometimes is very 
great. The fever is often so slight as to be discovered only when the 
temperature is taken five or six times in the twenty-four hours. The 
other symptoms are of a very indefinite character; there may be slight 
edema of the lower extremities, general muscular weakness, so that the 
child is easily fatigued, loss of appetite, coated tongue, constipation, head- 
ache, muscular pains, and often cough from a slight bronchitis. These 
symptoms may depend upon many conditions other than malaria, even 
when they are seen in a malarial district. The only positive evidence of 
malaria in such cases is the presence of the malarial organisms in the 
blood. Even the swollen spleen, anemia, and slight fever, which are 
often looked upon as diagnostic, may be present in cases of anemia with 
which malaria has nothing whatever to do. 

Diagnosis. — The positive diagnosis of malaria rests upon the demon- 
stration of the malarial organisms in the blood. They will be found in 
nearly all the cases provided a careful examination is made a few hours 
before the paroxysm, and also that no quinin has been administered. 
When their number is small they may be missed at the height of the 
fever, although they may readily be found just before the temperature 
begins to rise. While a positive result is conclusive, a negative one is not 
always so because of the impossibility of fulfilling all the above condi- 
tions. This fact and lack of experience in blood examinations make it 
necessary for a large part of the profession to make the diagnosis by the 

the third day the temperature was again high and accompanied by cough ; coarse 
rales were found throughout the chest, and fine rales at the right base; it was 
then thought that pneumonia was developing. On the fourth day all the symp- 
toms were so much improved that the infant was regarded as convalescent. At 
6 p.m. the temperature was normal, and the infant went to sleep quietly. At 
9.30 p.m. he awoke with a temperature of 104° F., extreme restlessness, and 
marked dyspnea. In half an hour his symptoms had increased to a poinl where 
he seemed likely to die. He became cyanotic, the respirations were of a panting 
character and rose nearly to one hundred a minute, and he coughed with almost 
every breath; the pulse was scarcely perceptible. The severe symptoms con- 
tinued for about an hour, then passed away gradually, and at the end of two 
and a half hours they had completely disappeared, and the child was in ;i quiet 
sleep which continued until morning. Malaria was now suspected, and the diag- 
nosis established by the discovery of the organisms in the blood. The spleen 
was at this time much enlarged; the signs in the chest were those only of bron- 
chitis of the large tubes. Quinin was given in full doses, and immediately con- 
trolled the temperature and the pulmonary symptoms. 



H46 THE SPECIFIC INFECTIOUS DISEASES 

other symptoms. These, in the order of their importance, we would 
place as follows: Prompt curability (especially in cases of fever) by 
quinin ; distinct periodicity in the symptoms ; enlargement of the spleen ; 
and a history of an exposure in a district known to be malarial. Particular 
importance is to be attached to the therapeutic test. Eecent experience 
emphasizes more and more strongly the fact that quinin has very little 
influence upon fevers which are not malarial, and, conversely, that a 
fever immediately and permanently controlled by quinin is pretty certain 
to be malarial. 

The fever and recurring chills of pyelitis are often attributed to 
malaria. Many conditions accompanied by an enlarged spleen may be 
confounded with malaria, especially simple anemia, leukemia, rickets, 
and syphilis. While malaria may be multiform in its manifestations, 
the physician can fall into no more serious error, even in a malarial dis- 
trict, than to regard all ailments with obscure or indefinite symptoms as 
malarial, neglecting careful physical and blood examinations, by which 
means alone an accurate diagnosis is reached. 

Prognosis. — Although it is seldom fatal in itself, an attack of malaria 
in a young child may so undermine his constitution that he may suc- 
cumb to some other acute disease. Cases are often difficult to cure 
while the patient remains in the malarial district, and when frequent 
re-infection occurs. In other circumstances and with proper treat- 
ment the prognosis of malaria is good. 

Treatment. — Prophylaxis. — More exact knowledge regarding the eti- 
ology of malaria makes it possible for much to be done in the way of 
prevention. Besides the general measures proposed for- the extermina- 
tion of the mosquitoes concerned, emphasis should be laid upon the neces- 
sity, in the case of young children, of protecting them against the bites 
of mosquitoes in localities which are or which may possibly be malarial. 
This can be done by a more thorough use of mosquito netting and by 
using upon exposed parts of the body lotions or ointments containing 
menthol, pennyroyal, turpentine, or other • substances which keep these 
pests away. The general treatment is symptomatic, and is to be con- 
ducted as in all acute febrile diseases. In the cold stage, stimulants or a 
hot bath may be required ; in the hot stage, ice to the head and frequent 
sponging. 

Methods of Administration of Quinin. — For infants our own prefer- 
ence is to give the sulphate in an aqueous solution, two or five grains 
to the teaspoonful, according to the age of the patient. Most infants 
take such a solution with less difficulty and vomit it less frequently than 
the combinations with the various vehicles supposed to cover its taste. 
! f the quinin is given at night upon an empty stomach, vomiting seldom 
occurs. If repeated vomiting makes it impossible to give quinin by 



MALARIA 1147 

mouth it may be given hypodermic-ally. For this purpose the bimuriate 
of quinin and urea is perhaps the most satisfactory preparation; but 
the bisulphate may be used. Both are more or less irritating and there 
usually follows some induration at the site of the injection, which may 
last a long time. While the hypodermic use of quinin is sometimes 
invaluable it should not be employed in infants except in serious attacks 
and when the diagnosis has been established. The frequent repetition 
of the hypodermic injections should be avoided; in most cases, two or 
three good doses are sufficient, the effect being continued by quinin given 
by other methods. 

For children from two to seven years old the taste of quinin must 
be concealed. An aqueous solution of the bisulphate may be mixed with 
the syrup of sarsaparilla, orange, or yerba santa ; or the sulphate may be 
given in suspension in one of the same vehicles, the mixture being made 
just before the dose is taken; otherwise the partial solution of the drug 
will render the whole dose exceedingly bitter. When the dose required is 
not large, as in the milder cases, the lozenges of the tannate of quinin 
combined with chocolate answer the purpose admirably, for these are so 
nearly tasteless that children will take them without difficulty. Each 
lozenge usually contains one grain of the tannate, which is equivalent to 
about one-third of a grain of the sulphate of quinin. A similar lozenge 
containing one grain of the sulphate may be made, which is often taken 
by children without the slightest objection. 

For children over seven years old, the same methods of administra- 
tion may usually be employed as in adults. It is always preferable to 
give quinin in solution, or if not so, in capsule, but not in pill form. 

In a case with well-marked paroxysms the quinin should if possible 
be given in the interval, with the largest dose about four hours before 
the expected paroxysm. With infants this plan is sometimes imprac- 
ticable, as frequent small doses are usually better borne by the stomach 
than a few large ones. In them also vomiting seems less likely to occur 
when it is given on an empty stomach. For this reason it is advantageous 
to give the drug at regular two- or three-hour intervals during the night, 
and omit all medication during the day. 

Dosage. — Relatively much larger doses of quinin are required for 
young children than for adults. Except for its tendency to disturb the 
stomach, quinin is borne remarkably well by Little patients. Generally 
too small doses are given. An infant of a year with a sharp attack of 
malarial fever will usually require from eight to twehe grains of the 
sulphate (ten to fourteen grains of the bisulphate) daily. Occasionally 
we have found it necessary to give double the quantity referred to. It 
is useless to expect to control an acute attack of malaria by such doses 
as one grain three or four times a day. Children from five to ten years 



1148 THE SPECIFIC INFECTIOUS DISEASES 

old require almost as large doses as do adults. Xone of the substitutes 
for quinin are to be relied upon in acute cases. 

In chronic cases, arsenic and iron are usually required in combination 
with smaller doses of the quinin than those mentioned. For children 
over seven years old, AYarburg^s tincture may be employed. In most 
chronic cases a cure can be effected only by a change of climate. 

The masked and irregular manifestations of malaria are to be 
treated in the same manner as cases of malarial fever. 



SECTION X 
OTHEE GENERAL DISEASES 

CHAPTER I 
RHEUMATISM 

Rheoiatis}! manifests itself in children by quite a different group 
of symptoms from those seen in adults; for this reason the disease was 
formerly supposed to be a rare one in early life. It is only within recent 
years that its frequency and its peculiarities have come to be appre- 
ciated. For our present understanding of the subject we are indebted 
largely to the work of English physicians, especially Cheadle, who has 
brought out more fully than any one else the close connection existing 
between many conditions formerly not regarded as rheumatic. One 
who has in mind only the adult types of articular rheumatism, and 
regards arthritis as a necessary symptom for a diagnosis, will overlook 
in early life many manifestations which are clearly the result of the 
rheumatic poison. There is seen at this period a group of clinical phe- 
nomena, which often occur in combination or in succession, whose asso- 
ciation was not understood until they were all discovered to be related 
to rheumatism. Sometimes one member of the group and sometimes 
another is first seen, but when one has appeared others are likely soon 
to follow. 

Rheumatism in childhood, then, is manifested not alone by arthritis 
with acute or subacute symptoms, but by a large number of other condi- 
tions which are not to be regarded in the light of complications, but rather 
as forms of the disease. 

Etiology. — It is not in the province of this work to discuss the vari- 
ous theories regarding the nature of rheumatism and its exciting cause. 
The drift of medical opinion to-day is strongly toward the view that 
acute rheumatism is an infectious disease, probably of microbic origin. 
Although the character of the microorganism is qoI yei satisfactorily 
determined, the observations of PoyntoD and Paine, Wassermann and 
others point to a diplococcus. dnder five years of age articular rheu- 
matism is not common, and in infancy it is extremely rare. We once saw, 
however, in a nursing infant, a typical attack of rheumatic fever with 
38 114!) 



1150 OTHER GENERAL DISEASES 

multiple joint lesions. The condition is, however, so exceptional that 
one should be cautious in making the diagnosis of rheumatism in infancy. 
Most of the cases so regarded are examples of scurvy. After the fifth 
year both the articular and the other manifestations of rheumatism 
become very common, and occur with increasing frequency up to the 
time of puberty. 

Heredity is a very important etiological factor, and in fully two- 
thirds of the cases that have come under our care, a rheumatic family 
history was obtained. Of the other important causes, the most frequent 
are living in damp dwellings, direct exposure to cold and wet, poor 
hygienic surroundings, and insufficient food. While seen among all 
classes, rheumatism is more common among those who are badly housed. 
Attacks of rheumatism occur at all seasons, but are much more frequent 
in the spring months. One attack strongly predisposes to a second, and 
in most cases there is a history of a large number of attacks of greater 
or less severity. Among our own patients, girls have been affected with 
greater frequency than boys. 

Symptoms. — The General and Articular Manifestations. — The clini- 
cal types of rheumatism in children present very notable contrasts to those 
seen in adults. A typical attack of acute articular rheumatism such 
as is seen in adult life, with a sudden onset, high temperature, severe in- 
flammation of several joints, profuse acid perspiration, and occasional 
delirium, is rarely seen in a child under eight or ten years old. In most 
of the attacks in childhood the onset is not very acute, the temperature 
is but slightly elevated — only 100° or 101.5° F. — the swelling and pain 
are moderate, and the redness is often absent. The number of joints 
involved is generally small, those most frequently affected being the 
ankles, the knees, the small joints of the foot, the 'wrists, or the elbows. 
These symptoms are often not severe enough to keep the patient in bed, 
and only the pain in the joints of the lower extremities prevents him 
from walking. The duration of these attacks is from one to three weeks, 
and in the course of a month most of them recover even without 
treatment. 

Not infrequently the symptoms are limited to a single joint, usually 
the hip, knee, or ankle. Possibly the joints of the upper extremity are 
affected oftener than would appear, but disease here is much more likely 
to be overlooked than when lameness is present. The swelling is moderate 
and may not be evident except on a close examination; in some cases 
there is none. There is stiffness of the joint, as shown by lameness, and 
there may be so much pain and soreness that the child refuses to walk 
altogether. Muscular spasm about the affected joint is often marked, 
and may be the most striking objective symptom. The tenderness is 
sometimes localized, but it may affect the ligaments, tendons, and even 



RHEUMATISM 1151 

the muscles. These symptoms may persist for two or three weeks and 
lead to a suspicion of incipient tuberculous disease of the joint. Kheuma- 
tism is distinguished by its more acute onset and usually by the presence 
of slight fever ; some elevation of temperature being the rule, though it is 
not often much over 100° F. A family history of rheumatism, or a 
history of previous similar attacks in the patient affecting the same or 
other joints, or other manifestations of rheumatism, are also of assistance 
in the diagnosis. Occasionally all doubt is removed by the disease 
extending to other joints, or by the development of endocarditis. In 
some cases the symptoms are less in the joints themselves than in the 
muscles, and they are frequently dismissed as simply "growing pains," 
having nothing characteristic about them except their occurrence in 
damp weather. 

Cardiac Manifestations. — These may occur when the articular symp- 
toms are very mild, and in some cases when the}' are entirely absent. 
The most frequent is endocarditis. This is much more often seen in the 
acute rheumatism of children than of adults, and probably occurs in the 
majority of all severe cases; if it does not come in the first attack, it is 
likely to be seen in the later ones. It frequently occurs with a mild 
rheumatic arthritis, often being unnoticed until valvular disease of con- 
siderable severity has developed. Sometimes there is only high fever 
with severe constitutional symptoms of an indefinite character, but no 
arthritis, and no suspicion that the attack is rheumatic until endocar- 
ditis is discovered. Such cases are not infrequent. If the patients are 
kept under observation, articular symptoms are almost certain to develop 
later, and often there are other manifestations of rheumatism, especially 
chorea. 

Pericarditis is much less frequent than endocarditis, and usually 
occurs in children over seven years old. It is often associated with en- 
docarditis. The most characteristic form of inflammation in early life is 
a sub-acute, dry, fibrous form, often resulting in great thickening with 
extensive adhesions, and frequently in obliteration of the pericardial 
sac. When once started it shows a strong tendency to recurrence and 
persistence. 

The heart is so frequently affected in the rheumatism of childhood 
that it should be closely watched whenever articular symptoms are pres- 
ent, no matter how mild they may be; and not only in these cases, but in 
all the conditions hereafter enumerated with which rheumatism is likely 
to be associated. 

Inflammations of other serous membranes — the pleura, peritoneum, 
and pia mater — were much more frequently ascribed to rheumatism in 
the past than now. There is reason Cor believing that on rare occasions 
the pleura may be involved, hut very exceptionally in young children. 



1152 OTHER GENERAL DISEASES 

There is no evidence that the peritoneum and meninges are directly 
affected by rheumatism. 

Torticollis when it occurs acutely is frequently rheumatic. This 
form is characterized by its sudden development, continuous spasm, the 
great amount of muscular soreness, the moderate pain, and the fact that 
it usually disappears spontaneously after a few days. Other manifesta- 
tions of muscular rheumatism are less characteristic and usually affect the 
muscles of the extremities. 

Anemia is almost invariably seen in rheumatic patients, both during 
and between the attacks. The effect of the rheumatic poison upon the 
blood resembles that of malaria. A secondary anemia develops, often 
of considerable severity. 

Chorea. — In the chapter upon Chorea we have already discussed the 
association of that disease with rheumatism and expressed our belief 
in a very close relationship existing between them. Not infrequently 
chorea is the first manifestation of a rheumatic diathesis, to be fol- 
lowed soon by articular symptoms or by endocarditis without such symp- 
toms. In other cases chorea and acute endocarditis occur together with- 
out articular symptoms, or all three may be associated. Whichever of 
the three conditions is first seen, the physician should always be on the 
lookout for the others. The frequency of rheumatism in choreic patients 
has been variously estimated by different observers; in our own cases 
over fifty per cent have given unmistakable evidence of a rheumatic 
diathesis. 

Tonsillitis. — The association of tonsillitis and pharyngitis with rheu- 
matism appears in many cases to be a close one. Children who are the 
subjects of frequent attacks should be regarded as probably rheumatic, 
and closely watched for other signs of that disease. Acute tonsillitis 
often ushers in an attack of rheumatic arthritis, and occasionally acute 
endocarditis without articular symptoms. The nature of the relationship 
is not yet fully explained ; by many the tonsils are regarded as the struc- 
tures in which the organisms of rheumatism first obtain a foothold. 

Subcutaneous Tendinous Nodules. — General attention was first drawn 
to these as a manifestation of rheumatism by Barlow and Warner, in 
1881, who described them as "oval, semi-transparent, fibrous bodies like 
boiled sago grains." They are most frequently found at the back of the 
elbow, over the malleoli, at the margin of the patella; occasionally on 
the extensor tendons of the hands, fingers, or toes, or over the spinous 
processes of the vertebrae or the scapulae. They are composed of fibrin, 
cells, and fibrous tissue, and vary in size from a large pin's head to a 
small bean, sometimes being as large as an almond. The nodules may 
come in crops, lasting for a few weeks and then disappear, or they may 
last for months. An eruption of nodules is usually coincident with other 



RHEUMATISM 1153 

rheumatic manifestations. These nodules are better felt than seen, 
although they may be visible if the skin is tightly drawn. They are 
certainly not common in this country; and although we have made it a 
rule to examine rheumatic patients for them, we have seen them but 
seldom^, and they have been prominent in only eight or ten cases. This 
has also been the experience of most observers in this country. From 
published reports, however, they appear to be much more frequent in 
England. There can be no doubt regarding the connection of these 
nodules with rheumatism. 

Erythema. — The connection between rheumatism and the various 
forms of erythema — marginatum, papulatum, and nodosum — has been 
very clearly shown by Cheadle. None of these is a frequent condition 
in childhood, but when seen it should always suggest rheumatism. 

Purpura. — The association of purpura with rheumatism is at times so 
close that there can be little doubt of the close connection between the two 
conditions. Eheumatic purpura, however, is quite distinct from the 
other forms of purpura, and is a much less frequent disease. 

Diagnosis. — In order to recognize rheumatism in a child, one must 
free his mind from preconceived notions of the disease drawn from its 
manifestations in adults, as very few cases correspond to the adult type 
of acute rheumatism. In early life the disease is recognized not by any 
one or two special symptoms, but by the association or combination of a 
number of conditions which may appear unrelated. In determining 
whether or not any given set of symptoms is due to rheumatism, one 
should consider: (1) the family history, since in early life heredity is 
so important an etiological factor ; (2) the previous history of the patient, 
not only as regards articular pains and swellings, the slight joint-stiffness 
without swelling, the indefinite wandering pains in damp weather, and 
the so-called growing pains, but also the previous existence of chorea, 
frequent attacks of tonsillitis, torticollis, or erythema; (3) the examina- 
tion of the patient, which should include a careful search for tendinous 
nodules, as well as a thorough examination of the heart for signs of 
endocarditis or pericarditis, and, in cases which are at all acute, the 
temperature. In doubtful cases with monarticular symptoms much im- 
portance is to be attached to the presence of slight fever, the abrupl 
onset, and tenderness of the neighboring muscles ami tendons — all 
occurring without a history of traumatism. Rheumatism is more often 
overlooked than confounded with other diseases; although in childhood 
multiple neuritis and tuberculous and syphilitic bone disease are often 
mistaken for it, and in infancy the same is true of seurw. The extreme 
infrequency of rheumatism during the first two years of life should 
always make one sceptical regarding it. In an infant, when the symp- 
toms are confined to the legs and are not accompanied by fever, they 



H54 OTHER GENERAL DISEASES 

are almost certain to be due to scurvy, even though the gums are normal 
and ecchymoses have not appeared. Multiple gonococcus arthritis has 
often been diagnosticated rheumatism. Many cases of general sepsis, 
especially such as originate from the tonsils or the teeth, may be accom- 
panied by joint swellings resembling rheumatism. 

Prognosis. — Eheumatism in a child is in itself seldom if ever danger- 
ous to life. In the great majority of cases the articular symptoms soon 
disappear, even without special treatment. The danger from the disease 
consists in its cardiac complications. One attack of rheumatism is almost 
certain to be followed by others, and when once the heart has been 
affected it* lesions are likely to increase with each recurrence of the 
disease. 

Treatment. — Eheumatism in children derives its chief importance 
from its relation to cardiac disease. Cardiac complications are so fre- 
quent and so serious that everything possible should be done to avert 
rheumatism from those who by inheritance are especially predisposed to 
it, to prevent its recurrence in a child who has once had the disease, and 
during an attack to prevent the heart from becoming involved. The 
relation of diet to rheumatism is very imperfectly understood. Our own 
opinion is that there is no close connection between the two. The under- 
clothing should be of wool during the entire year, in summer the lightest 
weight being worn. The feet should be carefully protected, and exposure 
in damp weather avoided. Indoor occupations should be chosen for 
rheumatic boys. 

The tendency to recurrence is so strong in this disease that a child of 
rheumatic antecedents, who has shown in the various ways mentioned a 
marked predisposition to rheumatism, and who has had an attack, even 
though a mild one, should, if possible, spend the winter and spring in 
some warm, dry climate, or even remain there permanently. Otherwise 
in most such children, it is only a question of time when, with the re- 
peated attacks, the heart will become involved. 

To avert the danger of cardiac complications during an attack of 
rheumatism, or to limit their extent, there are two things which should 
invariably be insisted on : first, to confine to the house and in a warm 
room every child with rheumatic pains, no matter how mild; secondly, 
if fever is also present, to keep the child in bed while it continues, even 
though it may not be above 100.5° F. Absolute rest and the equable 
temperature thus secured are unquestionably of more importance than 
anything else in protecting the heart during a rheumatic attack. With 
these precautions must be combined an early diagnosis. In very many, 
perhaps in most cases, the harm is done before the true nature of the 
disease is suspected, the symptoms being dismissed as of slight impor- 
tance because the articular manifestations are not very severe. Children 



DIABETES MELLITUS 1155 

who have once had rheumatism should be closely watched during chorea 
and other diseases related to rheumatism, the heart should be frequently 
examined, and the physician should be on the alert for the first articular 
symptoms. 

Aside from the measures just mentioned, the treatment of rheuma- 
tism in childhood is to be conducted very much like that of adult life. 
In most acute attacks either salicylate of soda (gr. v every three hours 
to a child of five years), aspirin, oil of wintergreen, or salicin should 
be given; as the majority of cases are not very acute, marked improve- 
ment is by no means always obtained by these drugs. Alkalis should be 
given in all cases in combination with the salicylates, but particularly 
in those in which there is hyperacidity of the urine. Either the acetate 
or citrate of potassium or the bicarbonate of sodium may be used, a suffi- 
cient quantity being administered to render the urine alkaline. 

Quite as necessary as these drugs is the use of general tonics, par- 
ticularly iron and cod-liver oil. These should be given not only between 
attacks to fortify patients against their recurrence, but also in subacute 
cases which are sometimes influenced very little or not at all either by 
salicylates or alkalis. 

The importance of attention to pathological conditions in the tonsils 
and mouth in all children with recurring rheumatic attacks should not 
be overlooked; especially should diseased tonsils be removed and carious 
teeth and diseased gums receive appropriate treatment. 



CHAPTER II 
DIABETES MELLITUS 

In this chapter will be attempted only a description of the peculiar 
features which diabetes presents when affecting young patients. It is 
a rather infrequent disease in children. Of 1,360 cases of diabetes col- 
lected by Pavy, only eight were under ten years of age. In a series of 
700 cases collected by Prout, only one case was under ten years. In a 
series of 380 cases collected by Meyer, only one case was under ten years 
of age. More recent statistics have shown that the propori i<>n of children 
under ten among diabetics is not so small as would be indicated by these 
figures. Von Noorden has reported 84 cases in children under ten in 
about 3,000 cases of diabetes. We have ourselves seen more than thirty 
cases. 

Etiology. — Stern, in a series of 1 IT collected cases of diabetes in 
children, states that 47 were females and 'M males, the sex in the other 



1156 OTHER GENERAL DISEASES 

cases not being given. Of 26 of the cases observed by ns, 16 were in 
females and 10 in males. It seems that females are rather more fre- 
quently affected, in contrast with the marked preponderance of cases in 
males in adnlt life. Although extremely rare, cases have been observed 
during the first year of life. Statistics on this point are not altogether 
trustworthy, since some cases of temporary glycosuria have certainly 
been included. The youngest case that has come under our observation 
was in a boy of twenty-six months. 

Among the etiological factors heredity is one of the most important. 
Pavy reports the case of a child dying of diabetes at two years in whose 
family the disease had existed for three generations. Instances have 
been recorded of the occurrence of diabetes in four or five children of 
the same family. There was a family history of the disease in 11 out of 
26 patients under our care. Several of the cases reported in children 
have been preceded by injuries received upon the head. In a number 
of our own cases the disease has followed the consumption of large 
quantities of sugar for a long time. Often no adequate cause can be 
found. 

Symptoms. — The most important early symptoms are thirst, polyuria, 
and wasting; their development is often quite rapid. The thirst is in- 
tense, often leading children to drink four or five pints of fluid a day, 
or even more. The amount of urine passed varies from one to eight quarts 
daily. The specific gravity is from 1.026 to 1.040, and the amount of 
sugar usually large. Acetone, diacetic and /3-oxybutyric acids are also 
present in greater or less amount. Albumin is not infrequently found. 
Incontinence of urine is an important symptom, and often one of the 
earliest to be noticed. The wasting is usually quite rapid, so that a child 
may lose as much as six or eight pounds in a month. It is generally 
accompanied by anemia. The appetite may be poor; at times, however, 
it is voracious. Other symptoms of less importance are a dry mouth, 
scanty perspiration, irregular sleep, occasional epistaxis, furuncles and 
abscesses, decayed teeth, and genital irritation. 

The -course of the disease is much more rapid in children than in 
adults, and, as a rule, the younger the child the more rapid its progress. 
Without proper treatment, the great majority of the cases prove fatal 
in from three to six months from the time the symptoms are sufficiently 
marked to make the diagnosis possible. Occasionally, however, one of 
the milder type may be prolonged from one to two years. 

The progress of the disease is marked by continuous wasting, which 
may result in a striking degree of malnutrition and prove fatal. Some 
are carried off by intercurrent pneumonia or tuberculosis, but the ma- 
jority die comatose. When coma develops, the case may be considered 
hopeless, and death is likely to be postponed but a few days. The cause 



DIABETES MELLITUS 1137 

of diabetic coma has not been explained with entire satisfaction. It 
occurs when there has been a prolonged and severe drain upon the 
alkaline defenses of the body by the abnormal acids which are not, in 
themselves, directly poisonous. Acidosis is a regular accompaniment of 
coma. Whether it is the sole cause is at the present time not entirely 
clear. 

Diagnosis. — Diabetes is apt to be overlooked, because of the com- 
mon neglect of urinary examinations in children. The prominent symp- 
toms, — thirst, polyuria, and wasting — when associated, should always 
attract attention. Enuresis, accompanied by marked wasting, is always 
suspicious. In some cases genital irritation may be the most prominent 
early symptom. A positive diagnosis is made only by an examination 
of the urine. 

Prognosis. — In few diseases has the prognosis been so bad as in 
diabetes in children. Senator has declared that diabetes in childhood 
is hopeless and all treatment useless. Yon Xoorden has said that with 
rare exceptions diabetes of childhood allows no respite. Such has also 
been our experience. From the more recent methods of treatment, espe- 
cially that recommended and elaborated by Allen, much more is to be 
expected. It has been sufficiently demonstrated that children can be 
maintained in a satisfactory condition, free from sugar and gaining 
gradually in weight for many months. We have now under observation 
five children who are doing well. Whether it will be possible for them 
to continue in this way and to reach adult life properly developed is a 
matter which only the future can decide. The outlook is, however, not 
so immediately dark as it has been. Intelligent observation and unremit- 
ting care are required both by the physician and parents. Without them 
good results are impossible. 

Treatment. — The indications for treatment are the same in children 
as in adults. Nothing more can be indicated here than the principles to 
be followed. In diabetes the carbohydrate tolerance is always very 
greatly diminished but usually not entirely lost. The purpose is to 
increase this tolerance. It can only be accomplished by protecting the 
carbohydrate mechanism from overstrain. If the tolerance is exceeded 
and sugar is excreted in the urine, the carbohydrate mechanism becomes 
less and less capable and the tolerance sinks. By preventing suga? 
excretion the mechanism improves and the tolerance rises. Patients 
should therefore be rendered Bugar free al the earliesl possible moment 
and constantly maintained sugar-free. This may be accomplished by tem- 
porary starvation until no sugar appears in the urine. Nothing what- 
ever by mouth should be allowed but clear broth and water. When 
there is no sugar excreted, well-cooked vegetables may be given, al first 
those containing but little carbohydrate, such as asparagus, spinach, 



1158 OTHER GENERAL DISEASES 

cabbage, onions and celery. After two or three days, nitrogenous foods, 
eggs, meat or fish may be allowed and later bacon, butter, olive oil and 
other fats. All of these are to be given in small amount at first and 
gradually increased until the nitrogenous and caloric needs of the body 
are satisfied. Loss of weight at first is to be expected and is not to be 
feared. Carbohydrate tolerance and not the weight curve is the index 
of progress. It is important that a record should be kept of the amount 
of carbohydrate taken and of the amount of sugar and acetone bodies 
excreted in the urine. Not more than 10 grams of carbohydrate a day 
should be given at first and any increase should be slowly made. Even 
if no sugar appears in the urine, it is advisable in severe cases to intro- 
duce a day of only broth feeding every ten days or two weeks, after 
which a low carbohydrate diet should be instituted and the carbohydrates 
again gradually increased. From time to time an attempt should be 
made to introduce articles of food such as oatmeal and milk in small 
quantities but never in amount sufficient to cause glycosuria. If sugar 
appears, a rapid and great reduction in the carbohydrates of the food is 
to be made and any increase should be instituted with caution, and not 
for several weeks should the amount be reached which was formerly 
followed by glycosuria. 



CHAPTER III 
PELLAGRA 



Although it is only recently that pellagra has attracted much atten- 
tion in this country, it is not likely that it has existed here for only a 
few years, but rather that it has not been recognized. At the present time 
its etiology is not understood. Three theories as to its cause have been 
advanced. The first and the one longest held is that it is due to the 
eating of spoiled corn (maize). In this, toxic products are supposed 
to be produced by the growth of fungi or of bacteria. The second is 
that it is a parasitic disease transmitted by the bite of an insect (the 
gnat). The third, and the view which is becoming more and more 
widely accepted, is that it is due to a diet deficient in certain important 
constituents (vitamins), which places it in the same group as scurvy 
and beriberi. The recent observations of Goldberger have shown that 
recurrences of the disease may be prevented by a reduction in the amount 
of carbohydrate food, and by considerable increase in vegetable and ani- 
mal proteins, especially fresh milk, eggs, meat and leguminous vege- 
tables. His observations indicate that pellagra may be produced by giv- 
ing a diet which, though abundant, may consist chiefly of carbohydrates 



PELLAGRA 1159 

and from which fresh animal and vegetable proteins have been excluded. 

Pellagra is seen at all ages although it is comparatively rare in 
very young infants. After two years of age it is much more common. 
It is found with greatest frequency in the states of the South Atlantic 
Coast, although cases have been reported from almost every state in the 
Union and even from Canada. Pellagra is a disease preeminently of 
the warm months, — spring, summer and autumn. As soon as cool 
weather comes it usually diminishes much in severity and in frequency, 
but cases sometimes develop even during the winter. It is found chiefly 
among the poor living in unsanitary surroundings, but no class is entirely 
exempt. While it is found in cities as well as towns, it occurs more often 
in country districts. 

There are no characteristic anatomical lesions in pellagra. Cellular 
change in the brain is common. In the cord degeneration of the lateral 
and posterior columns is frequently found, but usually only in cases that 
have existed for many months or years. 

Symptoms. — The symptoms in a well-marked case are easy to recog- 
nize, but in the mild form the disease may be almost impossible to detect, 
and it may be a long time before a definite conclusion as to the diagnosis 
can be reached. There are three chief symptoms — the cutaneous lesions, 
the gastro-intestinal symptoms and those of the nervous system. The 
cutaneous or the gastro-intestinal symptoms are those first in evidence. 
The eruption is found chiefly on exposed surfaces and for this reason and 
because it often begins with the advent of warm weather, it is frequently 
mistaken for sunburn. The eruption begins as an erythema, but after a 
variable length of time exfoliation takes place, desquamation being in 
some cases very marked. The skin is thickened, rough and dry, although 
in exceptional circumstances vesicles and bullae may be found and 
ulceration even may take place. The eruption (Fig. 201) is found 
upon the hands, neck, face and feet, although it may spread far up the 
arms and legs and involve even portions of the trunk as well. It is 
strikingly symmetrical and the lesions are sharply outlined; when they 
are not so it usually indicates that the eruption is receding. There is a 
certain amount of brownish discoloration, its intensity depending some- 
what upon the complexion of the person affected. No itching is com- 
plained of, but a slight burning or tingling sensation. The nails are 
unaffected. The tongue is oftentimes red; it may be coated, with clear 
edges, or it may be dry and glazed. The papillae are often somewhat 
enlarged. The tongue may be swollen. In addition to the glossitis there 
may be also stomatitis and gingivitis. Burning in the mouth is an occa- 
sional complaint. 

The gastric symptoms are few. Vomiting is rare. Anorexia may be 
marked but at times there is a craving for unusual food. Diarrhea 18 



1160 



OTHER GENERAL DISEASES 



the rule. The stools are from two or three to as many as fifteen a day. 
They may be watery, but at times mucus and even blood are present. 
Prolonged constipation is rare, but the diarrhea often alternates with 
periods of constipation. 

The mental symptoms are not so marked in children as in adults. 




Fig. 201. — Pellagra. Boy, five years old; died of the disease five months later. 



Depression is often present. There is frequently a change in disposition, 
the children becoming dull, morose and peevish. An anxious, distressed 
facial expression is characteristic of marked cases. The reflexes are 
usually exaggerated. Ankle clonus is frequently present and there may 
be a decided tremor upon exertion. If the intestinal symptoms are 
marked, there may be great loss of weight. The progress of the symptoms 
is not usually continuous, but there are marked remissions and exacerba- 
tions. The disease often disappears in the fall and winter to return 



PELLAGRA 1161 

again the following spring and this may he repeated many times. It is 
for this reason difficult to say when the disease is really cured. The 
prognosis in children is better than that in adults but death may occur 
from a continuance of the diarrhea, from the development of marked 
malnutrition or from intercurrent infections. 

Treatment. — Xo specific remedy for the disease has yet been discov- 
ered. The gastro-intestinal condition should be treated symptomatically. 
Pellagrous mothers should not nurse their infants. They should be 
artificially fed or a wet-nurse should be secured. In children beyond 
the nursing age the diet should be a mixed one, suited to the age of the 
child so far as the gastro-intestinal symptoms will allow. Following the 
suggestions derived from Goldberger's observations, careful attention 
should be given to the food. A faulty diet in which carbohydrates, espe- 
cially corn meal, have been excessive should be replaced by one with an 
abundance of milk, eggs, fresh meat, peas and beans. The patient should 
be put in the best hygienic surroundings possible. Arsenic is believed to 
be of special value. It may be given by mouth in the form of Fowler's 
solution, but it is thought by many to be more effective when given hypo- 
dermatically. Sodium cacodylate may be used in doses of 1/12 to % 
grain repeated two or three times at intervals of several days. 



INDEX 



Abdomen, examination of, 39 ; growth of, 
25 ; in rickets, 254. 

Abscess, alveolar, 273 ; cerebral, 759 ; 
cerebral, in acute otitis, 943 ; hepatic, 
439 ; ischiorectal, 434 ; mammary. 117 ; 
multiple, in newly born, 86 ; peritoneal, 
445 ; peritonsillar, 307 ; psoas, in spinal 
caries, 911 ; retro-esophageal, 312 ; re- 
tropharyngeal, in Pott's disease, 293, 
908 ; subphrenic, 455. 

Acid, hydrochloric, increased by lavage, 
340 ; hydrochloric, in stomach digestion, 
317 ; in chronic gastric digestion, 341. 

Acidosis, 217, 365 ; treatment of, 372. 

Adenitis, simple, acute, 862 ; simple, 
chronic, 865. 

Adenoid vegetations of pharynx, 294 ; 
asthma from, 488 ; causing chronic 
nasal catarrh, 460 ; chronic laryngitis 
with, 472 ; in rickets, 255 ; with adeni- 
tis, 865. 

Adenoma, of umbilicus, 114. 

Agenesis, cortical, 779. 

Airing, when allowed out of doors, 8. 

Air-space required by infants, 10. 

Alalia, 711. 

Albumin water, preparation of, 164. 

Albuminuria, orthostatic or cyclic, 617 ; 
in chronic cardiac disease, 598 ; in 
chronic nephritis, 637 ; in measles, 986 ; 
in scarlet fever, 966. 

Alcohol, as stimulant, 54 ; as tonic, 55 ; 
effect of. on breast milk, 175 ; use of, 
in diet of nurse, 143. 

Amaurotic family idiocy, 788. 

Amebic colitis, 390. 

Amyloid degeneration, 441 ; in chronic 
bone disease, 907 ; of the intestines, 
391 ; of the liver, 391 ; of the spleen, 
391. 

Anemia, cardiac murmurs in, 607 ; perni- 
cious, 846 ; pseudoleukemia of infan- 
cy, 844 ; secondary, 841 ; treatment, 
847. 

Anesthetics. 66. 

Aneurism, 612. 

Antipyretic drugs, 53. 

Antipyretics, 51. 

Antitoxin, in tetanus, 92 ; eliminated by 
human milk, 143. 

Anuria, 621. 

Anus, fissure of the. 431 ; imperforate, 
118. 



Aorta, abnormal origin of, 582 ; aneurism 
of, 612 ; atheroma of, 612 ; hypoplasia 
of, 611 ; thrombosis of, 611. 

Aortic insufficiency, 600 ; stenosis, COO. 

Aphasia, functional, 711 ; in acquired 
cerebral paralysis, 786 ; after typhoid 
fever, 1064. 

Appendicitis, 418 ; diagnosis of, 421 ; 
treatment of, 422. 

Arm, paralysis of, at birth, 111. 

Arsenic, as a tonic, 55 ; dosage of, in 
chorea, 699. 

Arteries, hypogastric, in fetal circula- 
tion, 575 ; hypoplasia of, 611 ; umbili- 
cal, in fetal circulation, 575. 

Arthritis, acute, of infants, 900 ; atro- 
phic, 902 ; chronic, 902 ; gonococcus, 
653, 659, 900 ; rheumatic, 1150. 

Arthrogryposis (see Tetany). 677. 

Artificial feeding, 179 ; versus wet-nurs- 
ing, 16S. 

Ascaris lumbricoides (see Worms, Intes- 
tinal), 425. 

Ascites, 454 ; chylous, 435 ; in acute dif- 
fuse nephritis, 631 ; in cirrhosis of liver, 
440 ; with chronic peritonitis, 448 ; with 
tuberculosis of the peritoneum, 450. 

Asphyxia, death from, in young children, 
46 ; from overlying, 48 ; from aspiration 
of food, 48 ; from enlarged thymus, 
49 ; in convulsions, 675 ; in retropharyn- 
geal abscess, 292 ; in the newly born, 
69 ; from tuberculous bronchial lymph 
nodes, 1098 ; methods of resuscitation, 
72 ; sudden, in retro-esophageal ab- 
scess, 313. 

Aspiration, of chest, in empyema. 570. 

Asthma, 487 ; with adenoids, 297 ; simu- 
lated by tuberculous bronchial glands, 
1096 ; treatment, 491. 

Ataxia, Friedreich's, 820; in multiple 
neuritis, 831. 

Atelectasis, acquired, 553: in delicate in- 
fants, 554 ; causing sudden death, 49 ; 
congenital. 74. 

Atheroma, 612. 

Athetoid movements, 701 ; in acquired 
cerebral paralysis, 786 ; in birth paral- 
ysis, 783. 

Athetosis, 701. 

Atrophy, infantile (see MARASMUS), 227; 
muscular spinal, types of, 822 ; mus- 
cular neural, types of. 822. 



1163 



1164 



INDEX 



Babcock's centrifugal machine, 149. 

Bacillus, of diphtheria, 1020, 1041 ; dis- 
tribution of, in the body, 1023 ; in 
milk, 146 ; in healthy throats, 1041 ; 
in laryngeal diphtheria, 1041 ; non- 
virulent, 1041; of dysentery (Shiga), 
in ileocolitis, acute, 374 ; in gastro- 
intestinal intoxication, acute, 374 ; of 
Eberth, in typhoid fever, 1058 ; Klebs- 
Loeffler (see B. Diphtherie), 1020; 
lactis aerogenes, 319 ; of Pfeiffer, in 
influenza, 1130 ; pseudodiphtheria, 301 ; 
of tuberculosis, 1067 ; in acute broncho- 
pneumonia, 495. 

Backwardness, 792. 

Bacterium coli communis, 319 ; in appen- 
dicitis, 419 ; in peritonitis, 445. 

Bacterium lactis aerogenes, 319. 

Balanitis, 653. 

Band, abdominal, 1, 3. 

Barley water, directions for making, 164 ; 
use of, during first year, 198. 

Barlow's disease (see Scorbutus) 231. 

Bath, at birth, 1, 2 ; cold, 53 ; in acute 
bronchopneumonia, 524 ; in asphyxia, 
of newly born, 72 ; evaporation, 53 ; 
hot, 59 ; hot air, 59 ; vapor, 56 ; mus- 
tard, 59 ; bran, 60 ; tepid, 60 ; shower, 
60 ; cold sponge, 60 ; hot, in asphyxia 
of newly born, 72 ; in typhoid fever, 
1067. 

Bed-wetting, 662. 

Beef, raw scraped, 163. 

Beef broth, 163. 

Beef extracts, 163. 

Beef juice, 159. 

Beef preparations, 159. 

Belladonna, 56 ; elimination of, in milk, 
143 ; scarlatiniforin rash from, 970. 

Bile, physiological action of, 318. 

Bile ducts, congenital malformations of, 
78. 

Birth paralyses, 106. 

Bladder, control of, acquired, 663 ; ex- 
strophy of, 651 ; hemorrhage from, in 
newly born, 105 ; stone in, 667 ; train- 
ing to control, 4. 

Bleeders, 852. 

Blindness, hysterical, 705 ; transient, in 
pertussis, 1010. 

Blood, circulation of, in early life, 575 ; 
diseases of, 839 ; in chlorosis, 843 ; in 
leukemia, 849 ; in pernicious anemia, 
846 ; in pseudoleukemic anemia, 844 ; 
in secondary anemia, 841 ; transfusion 
of, 68. 

Blood vessels, diseases of, 611 ; aneurism, 
612 ; coarctation of the arch of the 
aorta, 611. 

Boil (see Furunculosis), 930. 

Bones, diseases of, 895 ; in hereditary 
syphilis, 1115; in late syphilis, HIS ; ! 
lesions of, in rickets. 244 ; microscop- I 
ical changes of, in rickets, 245 ; syphi- 



litic diseases of, 1118 ; tuberculous dis- 
eases of, 905. 

Bothriocephalus latus, 424. 

Bottles, nursing, choice and care of, 196. 

Bow-legs, in rickets, 253. 

Bradycardia, 609. 

Brain, diseases of, 719 ; abscess of, 759 ; 
atrophy and sclerosis of, 780, 784 ; 
atrophy and sclerosis of, in acquired 
cerebral paralysis, 780 ; cysts of, in in- 
fantile cerebral paralysis, 781 ; malfor- 
mations of, 719 ; tuberculosis of, 1080; 
tumor of, 762 ; weight of, 669. 

Bran bath, 60. 

Breast, abscess of, in newly born, 117. 

Breast-feeding, 166 ; schedule for, 171. 

Breast milk (see Milk, Woman's). 

Breath, offensive, in ulcerative stomatitis, 
279. 

Breathing, noisy, with adenoids, 296 ; 
stridulous, in diseases of the larynx, 
463, 469, 473 ; in retro-esophageal ab- 
scess, 314. 

Bright's disease (see Nephritis), 629. 

Bromids, elimination of, in milk, 143. 

Bronchi, catarrhal spasm of, 489 ; diph- 
theria of, 1026 ; foreign bodies in, 475 , 
lesions of, in acute bronchopneumo- 
nia, 498 ; lymph nodes of, in tubercu- 
losis, 1073, 1078 ; tube casts from, 
486. 

Bronchial glands (see also Lymph Nodes, 
Bronchial), 1095; enlarged, cause of 
asthma, 488 ; in acute bronchopneu- 
monia, 509. 

Bronchitis, acute catarrhal, 479 ; symp- 
toms of, 480, 483 ; treatment of, 483, 
485 ; capillary (see Bronchopneumonia, 
Acute), 497, 506; attacks of asthma 
resembling, 489 ; chronic, 486 ; chronic, 
in rickets, 246 ; diphtheritic, broncho- 
pneumonia in, 517 ; fibrinous, 485 ; 
treatment, 486 ; in pertussis, 1008 ; in 
typhoid fever, 1063 ; spasmodic (see 
Asthma), 489; tuberculous, 1087. 

Bronchiectasis, in chronic bronchitis, 487 ; 
in bronchopneumonia, chronic, 547. 

Bronchopneumonia, acute, 497 ; bacteri- 
ology of, 495, 496 ; complications in, 
518 ; complicating influenza, 517; com- 
plicating diphtheria, 517 ; complicating 
measles, 517 ; complicating pertussis, 
515 ; complicating rickets, 246 ; diag- 
nosis of, 519 ; etiology of, 497 ; lesionu 
in, 498 ; associated in the lung, 504 ; 
physical signs of, illustrated, 513 ; pro- 
tracted or persistent form of, 515 ; sec- 
ondary pneumonia with measles, 9S4 ; 
ileocolitis, associated with, 381 ; influ- 
enza, associated with, 1136 ; pertussis, 
associated with, 1008 ; diphtheria, asso- 
ciated with, 1036 ; prognosis of, 520 ; 
protracted cases of, 515 ; symptoms of, 
505 ; temperature charts of, 510 ; termi- 



INDEX 



1165 



nations of, 503 ; treatment of, 523 ; 
prophylaxis in, 523. 

Bronchopneumonia, chronic. 540, 542. 

Bronchopneumonia, tuberculous, 1086 ; 
rapid cases, 1087 ; protracted cases, 
1088; (see also Tuberculous Pneu- 
monia), 1086, 1092. 

Broths, directions for making, 163. 

Buhl's disease, 93. 

Buttermilk, 159, 207, 388. 

Calamine lotion, 929. 

Calculi, biliary, 443 ; renal, 646 ; pyelitis 
with, 647 ; vesical, 667. 

Calories, required daily by healthy in- 
fants, 180 ; method of calculating, 181 ; 
value of different foodstuffs in, 3 29, 
181. 

Cancrum oris (see Stomatitis Gan- 
grenous), 285. 

Carbohydrates, function of, in diet, 131. 

Carcinoma, of brain, 762 ; of stomach, 
345. 

Casein, 150, 183. 

Caseinogen, 150. 

Casts, in urine, of chronic nephritis, 637. 

Catarrh, of eustachian tube, in hyper- 
trophy of tonsils, 308 ; gastric, 337 ; 
nasal acute, 457 ; prophylaxis in, 459 ; 
chronic, 460 ; with adenoid growths, 
296 ; foreign bodies in nose, 460 ; nasal 
polypi, 461 ; rhinitis, simple chronic, 
461 ; epidemic, 1138 ; syphilitic, 462 ; | 
rhinopharyngeal, with adenoids, 296. 

Catheters, sizes required for infants, 615. 

Cellulitis, of abdominal wall with peri- 
tonitis, 445 ; of neck, in scarlet fever, 
964. 

Cephalhematoma, 97. 

Cereals, 164 ; allowed from third to sixth 
year, 212. 

Cerebral abscess, 761. 

Cerebral tumor, 762. 

Cerebral paralysis, infantile, 779 ; from 
hemorrhage, 106 ; etiology of, 106. 

Cerebrospinal meningitis (see Meningitis, 
Acute Cerebrospinal), 727. 

Chest, circumference of, 24 ; development 
of, 24 ; "funnel" chest, 24 ; lateral de- 
pressions of, in adenoids, 296. 

Chicken-pox (see Varicella), 994. 

Chloral, dosage and administration of, 56. 

ChlordBis, 843 ; treatment of, 847. 

Cholera infantum, 363 ; treatment of, 367, 
373. 

Chondrodystrophy, 897. 

Chorea, 694 ; endocarditis in, 596, 697 ; 
diagnosis of, 698 ; etiology of, 694 ; fol- 
lowing birth paralysis, 7S3 ; typhoid fe- 
ver, associated with, 1064; heart mur- 
murs in, 697 ; prognosis of, 60S ; hys- 
terical, 707 ; with adenoids. 297 ; in 
rheumatism, 895, 1152; pathology <>r. 
696; posthemiplegic, 701; in cerebral 



palsy, 783 ; prognosis of, 698 ; relation 
of. to rheumatism, 695 ; speech in, 697, 
711 ; symptoms of, 696 ; treatment of, 
698. 

Circulation, changes in, at birth, 575 ; 
fetal, 575 ; in early life, 575. 

Circulatory system, diseases of, 575. 

Cleft palate, 265. 

Clothing, at birth, 2 ; in summer, 3 ; at 
night, 3 ; in summer diarrhea, 368. 

Club-foot, with spina bifida, 799. 

Codein, dosage of, 56. 

Cod liver oil, as tonic, 54. 

Cold, antipyretic methods in use of : — 
ice cap, 52 ; sponging, 52 ; pack, 50 ; 
bath, 53 ; colon irrigation, 53. 

Cold sores, 269. 

Colic, habitual, 194 ; intestinal, 401 ; 
renal, 647. 

Colitis, acute (see Ileocolitis, Acute), 
373 ; amebic, 390 ; membranous, 379 ; 
membranous gastritis, with, 338. 

Collapse, in acute bronchopneumonia, 
treatment of, 525 ; in acute peritonitis. 
447 ; in ulcer of stomach, 343. 

Collapse, pulmonary (see Atelectasis, 
Acquired), 553. 

Colles's law, 1105. 

Colon, abnormal position of, 350 ; dilata- 
tion of, 408 ; in rickets, 254 ; follicular 
ulcer of, 377 ; hypertrophy of, 408 ; 
irrigation of, 53, 64 ; gastro-enteric 
intoxication, 371 ; in acute ileocolitis, 
388 ; membranous inflammation of, 3S5. 

Colostrum, 134. 

Coma, in diabetes mellitus, 1156. 

Compression-myelitis (see Myelitis), 804. 

Condensed milk, as a cause of rickets, 
241 ; composition of, 158 ; dilution of, 
for infants, 158 ; fresh, 158. 

Congenital diseases, ichthyosis. 875 ; my- 
atonia, 827 ; myotonia, 702 ; rickets, 
256 ; syphilis, 1104 ; tuberculosis, 1069. 

Conjunctiva, catarrhal inflammation of, 
in measles, 986 ; hemorrhage from, in 
newly born, 105. 

Constipation, in rickets, 254 ; chronic, 
403 ; treatment of, 405 ; dilatation of 
colon in, 408 ; anal fissure from, 431 ; 
early symptom of rickets, 248; from 
deficient fat in food, 241 ; in intussus- 
ception, 416. 

Contractures, hysterical, 706. 

Convulsions, 671 ; symptoms of, 672 ; 
treatment of, 675 ; causing death with- 
out other symptoms, 47; epileptic, 687; 
hysterical. 7<»7 ; in acquired cerebral 
paralysis, 785 : in cerebral hemorrhages, 

109; in congenital atelectasis. 7."» ; in 
pertussis, 100!); in rickets, 248. 
Cord, spinal, diseases of. 796; malforma- 
tions of. 796; meningitis, 802; myelitis, 
808; pressure-paralysis of, 808; tumors 
of. Mi' : weight of, 669. 



1166 



INDEX 



Cord, umbilical, care of. 1 ; separation of, 
2. 

Corpuscles, of blood, 839. 

Coryza, 457 ; early symptoms of measles, 
978; syphilitic, 462, 1111. 

Cough, hysterica], 707 ; from tuberculous 
bronchial glands, 1096; whooping (see 
Pertussis), 1003. 

Counterirritants, 57. 

Cow's milk (see Milk), 144. 

Craniotabes, early symptom in rickets, 
248. 

Cranium, syphilitic nodes on, 1119. 

Cream, 151 ; to secure different percent- 
ages of, 151, 152. 

Cream-gauge, 139, 149. 

Crede's method of preventing ophthalmia 
neonatorum, 1 ; treatment of ophthal- 
mia, 90. 

Cretinism sporadic, 881. 

Croup, bronchial, 485 ; catarrhal, 465 ; 
spasmodic, 465. 

Croupous tonsillitis, 300. 

Cry, causes and varieties of, 34 ; in dis- 
eases, 35 ; in colic, 402. 

Cryptorchidism, 652. 

Cups, dry, indications for, 58. 

Cyanosis, in acute bronchopneumonia, 506, 
508 ; in acute inanition, 220 ; in chron- 
ic cardiac disease, 598 ; in congenital 
atelectasis, 74 ; in congenital disease 
of heart, 583 ; in diphtheritic pa- 
ralysis, 834 ; in malaria, 1142, 1144 ; 
of face, from pressure at root of lung, 
1097. 

Cyclic vomiting, 331. 

Cyst, of brain, 762 ; of brain, in infantile 
cerebral paralysis, 781. 

Cysticerci, 423. 

Dactylitis, syphilitic, 1116 ; tuberculous, 
918. 

Deaf-mutism, 795. 

Deafness, following mumps, 1019 ; with 
adenoids, 296 ; with hypertrophy of ton- 
sils, 309 ; sudden, in late syphilis, 1122. 

Death, most frequent causes of, at differ- 
ent ages, 46 ; sudden, causes of, 48. 

Deformities, hysterical, 706 ; in rickets, 
248. 

Dental caries, 272. 

Dentition, 28 ; eruption of first teeth, 28 ; 
eruption of permanent teeth. 29, 30 ; 
delayed, 29 ; before birth, 28 ; difBcult, 
273 ; in rickets, 254. 

Development, conditions interfering with, 
30 ; muscular, 25 ; of body, 15. 

Dew's method of inducing artificial respi- 
ration, 73. 

Diabetes insipidus, 621. 

Diabetes mellitus, 1155. 

Diagnosis, general considerations in, 31. 

Diapers, 3. 

Diarrhea, general consideration of, 350; j 



deaths from, in New York in five years, 
350 ; prevalence of, during summer, 351 ; 
impure milk as a cause of, 352 ; observa- 
tions of the Rockefeller Institute, on 
association of feeding impure milk and 
diarrheal disease, 343 et seq. ; inflam- 
matory (see Ileocolitis, Acute), 373 
with acute intestinal indigestion, 357 
with chronic intestinal indigestion, 395 
summer, 357. 

Diathesis, exudative. 261 ; neuropathic, 262. 

Diet (see also Feeding), as cause of 
chronic constipation, 403 ; as cause of 
rickets, 241 ; in acute gastric-enteric 
infection, 368 ; in acute gastric indiges- 
tion, 328 ; in chronic constipation, 405 ; 
in chronic gastric indigestion, 340 ; in 
dental caries, 272 ; in eczema, 928 ; in 
intestinal indigestion, 388 ; in malnutri- 
tion, 230 ; in rickets, 258 ; in scurvy, 
239 ; of nurse, effect of, on milk, 142. 

Digestion, gastric, 315 ; duration of, 317 ; 
in infancy, 315 ; intestinal, 318. 

Digestive system, diseases of, 267. 

Digitalis, dosage of, 54 ; in cardiac dis- 
ease, 593, 604. 

Dilatation, of stomach, 341. 

Diphtheria, 1020 ; bacillus (see Bacillus 
of Diphtheria), 1020; bronchopneu- 
monia in, 517, 1028, 1036; blood in, 
1028 ; cardiac failure in, 1038 ; cardiac 
thrombi in, 1028 ; catarrhal, 1024, 
1030 ; complications and sequelae, 1036 ; 
diagnosis, 1038 ; bacteriological, 1041 ; 
clinical, 1039 ; from pseudodiphtheria, 

1041 ; distribution and mode of com- 
munication of, 1021 ; etiology of, 1020 ; 
fibrinous bronchitis in, 485 ; immunity 
to, 1022 ; immunization from, 1044 ; 
ileocolitis in, 1037 ; incubation, 1023 ; 
lesions, 1023 ; membrane, 973 ; proc- 
titis in, 432 ; myocarditis in, 605, 
1038 ; nasal syringing in, 1046 ; ne- 
phritis in, 1027, 1037 ; of esophagus, 
311 ; otitis in, 1036 ; paralysis after, 
1037 ; paralysis in, 832 ; prognosis of, 

1042 ; prophylaxis in, 1043 ; quarantine 
in, 1043 ; simulated after tonsillotomy, 
310 ; symptoms of, 1029 ; thrombosis in, 
1036 ; toxins of, 1024 ; treatment of, 
1045 ; local treatment of. 1046 ; serum 
treatment of, 1047 ; treatment of chil- 
dren exposed to, 1044 ; treatment of 
suspected cases of, 1043 ; laryngeal, 
1029. 1033, 1052 ; nasal, 1030, 1031 ; 
pseudo- (see Pseudo-diphtheria), 300; 
scarlatiniform erythema in, 970 ; ton- 
sillar, 1030. 

Diphtheria antitoxin, dosage of, 1048 
immunizing dose of, 1044 ; local and 
general effects of, 1049 ; other treat 
ment with, 1045, 1046 ; real and al 
leged dangers from, 1050 ; strength of 
1048 ; time of administration of, 1048 



IXDEX 



1167 



Diplegia, in birth paralysis. 783 ; from 
meningeal hemorrhage, 109 ; spastic, 
779. 

Disease, peculiarities of, in children, 30 ; 
etiology of, 30 ; symptomatology and 
diagnosis of, 31 ; pathology of, 41 ; 
prognosis of, 43 ; prophylaxis in, 50 ; 
therapeutics in, 51. 

Dover's powder, dosage of, 56. 

Dropsy (see also Edema), in acute dif- 
fuse nephritis. G32 ; in chronic cardiac 
disease, 591 ; in chronic nephritis, 636 ; 
in tuberculosis, 1091 ; without renal 
disease, 224. 

Drugs, administration of, 51 ; antipyretics, 
51 ; sedatives, dosage of, 56 ; stimu- 
lants, dosage of, 55 ; elimination of, in 
breast milk, 143 ; well borne by chil- 
dren, 57 ; not well borne by children, 57. 

Duodenum, congenital atresia of, 118. 

Dura mater, hematoma of, 724 ; throm- 
bosis of the sinuses of, 757. 

Dysentery (see Ileocolitis, Acute), 373. 

Dysphagia, hysterical, 708 ; in retro- 
pharyngeal abscess, 291. 

Dyspnea, evidence of. 34 ; from tuber- 
culous bronchial lymph nodes. 1096 ; in 
acute catarrhal laryngitis, 469 ; in ca- 
tarrhal spasm of larynx, 466 ; in chronic 
cardiac disease, 597 ; inspiratory, in 
retro-esophageal abscess, 313 ; from 
pressure of abscess on pneumogastric, 
314 ; spasmodic, in asthma, 489. 

Dystrophy, muscular, 824. 

Ear. middle, inflammation of (see Otitis), 
938 ; in measles, 986 ; in scarlet fever, 
965. 

Ecchymoses, on purpura, 857 ; in scurvy, 
235 ; in leukemia, 851. 

Echinococcus, of liver, 443. 

Eclampsia (see Convulsions), 671. 

Ecthyma gangrenosa, 932. 

Ectocardia, 582. 

Eczema, 923 ; etiology of, 924 ; diagnosis 
of, 926 ; treatment of. 927 ; intertrigo, 
920. 

Edema, in acute diffuse nephritis, 632 ; in 
anemia, 842 ; in chronic nephritis, t',:',t; ; 
in cardiac disease, 584: in leukemia, 
851 : of face, from pressure at root of 
lung. 1097 : general, in marasmus. 224. 

Edema glottidis. 441 ; in corrosive esopli- 
agitis. 312; in quinsy, 308. 

Emboli, infections, in malignant endo- 
carditis. 604. 

Embolism, 612; in diphtheria, 1036. 

Emphysema. .")."."» ; symptoms. ."."7 ; acute, 
in bronchitis of infants. 478; in acute 
bronchopneumonia, 505 ; in pertussis, 
1009. 

Empyema. 563 : lesions. 563 : symptoms, 
.".tie, ; diagnosis, ~<<>~ : treatment. 570 ; in 
acute bronchopneumonia. 504. 



Encephalocele, 720 ; symptoms of, 721 ; 
treatment of, 722. 

Endarteritis, syphilitic, of brain, Hon ; 
tuberculous, 748. 

Endocarditis, acute simple. 594 ; lesions, 
595 : symptoms, 596 ; treatment of. 602 ; 
in chorea, 593 ; chronic (see also 
Heart, Valvular Disease*. ~>97 ; fetal, 
579 ; in chorea, 697 ; in rheumatism, 
1152 ; malignant, 004. 

Enemata, 65 ; nutrient. 66 : drug's by. 66 : 
astringent, in chronic ileocolitis. 389 : 
in chronic constipation. 407 ; in colic 
402 ; injuries to rectum from, 431. 

Enuresis. 662. 

Epilepsy, 6S6 ; diagnosis of, 691 ; hyster- 
ical, 707 ; in acquired cerebral paralysis, 
786 ; in birth paralysis, 783 ; Jack- 
sonian, in cerebral tumor, 765 ; mental 
condition in, 690 ; prognosis of, 692 ; 
status epilepticus, 691 ; types of symp- 
toms, 688 ; treatment of. 692. 

Epiphyseal separation, in acute arthritis, 
900 ; in scurvy. 237 : in syphilis. 867. 

Epiphyses, enlargement of. in rickets, 253 ; 
in syphilis, 1106. 

Epiphysitis (see Arthritis Acute), 900; 
syphilitic, 1100, 1118. 

Epispadias, 651. 

Epistaxis, 463 ; in anemia, 842 ; in per- 
tussis, 1008 ; in purpura, 857. 

Epitrochlear lymph nodes, in syphilis, 
1125. 

Erb's paralysis, 111. 

Erysipelas, in newly born, 86. 

Erythema, following diphtheria antitoxin. 
1050 ; intertrigo, 926 : in intestinal in- 
digestion. 397; in rheumatism. 11":;: 
scarlatiniform causes. 970. 

Esophagitis, acute, 311 ; catarrhal, 311 ; 
corrosive, 312. 

p]sophagus, diseases of, 311 ; abscess lie- 
hind, 312 ; congenital narrowing of, 
311 ; congenital obstruction in. 311 ; 
diphtheria of, 1026 : malformation 
of. 311; stricture of, 311; thrush in, 
311. 

Examination, of sick child, 34. 

Exercise, importance of. 7 : caution re- 
garding, in heart disease. 603; in ane- 
mia, S4S. 

Exstrophy of bladder, 651 ; exudative 
diathesis. 261. 

Eye, keratitis, Interstitial, in syphilis. 
1121 : care of. at birth, i. :: ; dipb 
theritic paralysis of. 834; early use of. 
26; ectropion of. in congenital Ichthy- 
osis, 920; Inflammation <>r, in newly 
born, 89; in measles. 986; nystagmus, 
701. 

Pace, expression of. in disease, 84; cyan 
osis mihI edema of. from pressure at 
root of lung, 1097. 



1168 



INDEX 



Facial paralysis at birth, 110 ; acquired, 
peripheral, 836 ; in otitis, 944. 

Feces, 319; of milk diet, 319; of mixed 
diet, 320 ; incontinence of, 435. 

Fat, determination of, in milk, 140 ; in 
the feces, 319 ; lack of, a cause of 
rickets, 241 ; in woman's milk, 135 ; 
percentage of, in modification of cow's 
milk, 184, 187, 188 ; symptoms from 
deficiency of, in food, 193 ; symptoms 
from excess in food, 192, 194 ; function 
of, in diet, 131. 

Fatty degeneration, of the newly born, 93. 

Feeding, artificial, principles of, 181 ; 
rules for, 189, 197 ; indications for 
special variations in, 192, 195 ; sched- 
ule for first year, 189 ; versus wet nurs- 
ing, 168 ; breast, schedule, for, 171 ; 
other than milk, first year, 198 ; daily 
dietary from fifteen to twenty months, 
211 ; for healthy infants, second year, 
209 et seq.; difficult cases, 200 et seq.; 
from third to sixth year, 211 ; articles 
allowed, 211 ; articles forbidden, 213 ; 
during acute illness, 214 ; in infants, 
214 ; older children, 214 ; during periods 
of excessive heat, 367 ; by gavage, in 
acute illness, 214 ; nasal, 64 ; in acute 
intestinal indigestion and diarrhea, 357 ; 
methods of, in etiology of diarrhea, 
351 ; mixed indications for, 179 ; simple 
rules in, 214. 

Fever from insufficient nourishment, 172 ; 
inanition, 122 (see also Temperature). 

Finger (see Dactylitis). 

Fingers, clubbing of, in congenital heart 
disease, 584 ; food intoxication, 365. 

Fissure of the anus, 431. 

Flatulence, cause of colic, 402 ; in intes- 
tinal indigestion, 397. 

Flexner's serum for cerebrospinal menin- 
gitis, 738. 

Fetal circulation, 575 ; endocarditis, 579. 

Fetus, evidences of syphilis in, 1106. 

Follicular ulceration, of intestine, 377. 

Fontanel, bulging of, in cerebrospinal 
meningitis, 735 ; bulging of, in menin- 
geal hemorrhage, 109 ; bulging of, in 
tuberculous meningitis, 751 ; closure 
of, 22 ; in cretinism, 883 ; in rickets, 
250. 

Food, constituents, 128 ; protein, 129 ; 
fats, 131 ; carbohydrates, 131 ; mineral 
salts, 132 ; water, 133 ; farinaceous, a 
cause of eczema, 928 ; in chronic indi- 
gestion, 340 ; second year, 209 ; im- 
proper, in etiology of diarrhea, 351 ; of 
dental caries, 272 ; regurgitation of, 
causes and treatment, 193. 

Foods, infant, 165 ; cause of rickets, 241 ; 
cause of scurvy, 232 ; indicated, in 
chronic constipation, 405. 

Foreign bodies, swallowing of, 339 ; in 
the larynx, 471. 



Fractures, green-stick, in rickets, 244, 

252. 
Freeman's pasteurizer. 155. 
Friedreich's ataxia, 820. 
Frohlich's syndrome, 767. 
Fruit, best time for giving, 211 ; during 

second year, 211 ; during third to sixth 

year, 211. 
Furunculosis, 887. 

Gangrene, of the face in noma, 286 ; of 
intestine, in intussusception, 413 ; of 
lung, 552 ; in acute bronchopneumonia, 
505 ; in lobar pneumonia, 528 ; in scar- 
let fever, 969 ; in measles, 985. 

Gangrenous stomatitis, 285. 

Gastritis, acute, 335 ; symptoms, 337 ; 
treatment, 338 ; chronic, 339 ; ulcers in, 
342; toxic (see Gastritis Corrosive), 
338. 

Gastro-enteritis (see Acute Intestinal 
Indigestion and Diarrhea), 357; in 
newly born, 85. 

Gavage, 63 ; in acute illness, 215 ; in 
acute inanition, 221 ; in diphtheria, 
1046 ; in premature infants, 13. 

Genital organs, diseases of, 650 ; care of, 
in newly born, 4 ; malformations of, 
650 ; female, gangrene of, 285 ; females, 
diseases of, 655 ; hemorrhage from, in 
newly born, 105 ; males, diseases of, 
653. 

Gingivitis, in dental caries, 272 ; in 
scurvy, 234, 235. 

Glands, bronchial (see Lymph Nodes, 
Bronchial), 1095. 

Glands, lymphatic (see Lymph Nodes), 
860. 

Glioma of brain, 762 ; of spinal cord, 819. 

Gliosarcoma of brain, 763. 

Glossitis, 270. 

Glottis, edema of the, 471. 

Gonococcus, differentiation of, 658 ; in 
gonorrheal stomatitis, 284 ; in specific 
urethritis, 653 ; vaginitis, 656. 

Grippe, 1138. 

Growing pains, rheumatic, 1151. 

Growth, conditions interfering with, 
31 ; of body, 15 ; extremities, 21 ; trunk, 
21. 

Gumma, syphilitic (see Syphilis Le- 
sions), 1106; in syphilitic bone disease, 
1118 ; of brain, 762. 

Gums, abscess of, 272 ; bleeding in ulcer- 
ative stomatitis, 279 ; inspection of, 38 ; 
lancing, 275 ; spongy and bleeding, in 
scurvy, 234, 235 ; in ulcerative stomat- 
itis, 279. 

Habit-spasm, 700. 

Habits, injurious, 714. 

Hematemesis, 345. 

Hematoma of the sternomastoid, 94. 

Hematuria, 619 ; in newly born, 194 ; in 



INDEX 



1169 



purpura, 856; in pyelitis, 645; 
in scurvy, 237 ; in tumors of kidney, 
641. 

Hemoglobinuria, 619 ; epidemic, 92 ; par- 
oxysmal, 620. 

Hemophilia, 852. 

Hemorrhage, from stomach, 345 ; in 
hemophilia, 852 ; intra-alveolar, in 
acute bronchopneumonia, 500 ; internal, 
causing sudden death, 46 ; intestinal, 
from tuberculous ulcer, 394 ; in typhoid 
fever, 1063 ; meningeal, causing birth 
paralysis, 779 ; in acquired cerebral 
paralysis, 781 ; in acute bronchopneu- 
monia, 519 ; in convulsions, 672 ; men- 
ingeal, in pertussis, 1008 ; meningeal, 
in purpura, 855 ; nasal, in diphtheria. 
1037 ; pulmonary, in cardiac cases, 597 ; 
rectal, from ulcer, 433 ; in leukemia, 
850 ; in measles, 986 ; in pertussis, 
1008 ; in pernicious anemia, 847 ; in 
purpura, 855 ; in the newly born, 96 ; 
visceral, 100 ; in scurvy, 237 ; in syph- 
ilis, 1113. 

Hemorrhagic disease of the newly born, 
98. 

Hemorrhoids, 435 ; in chronic constipa- 
tion, 404. 

Harelip, 266. 

Hay fever, 490. 

Head, circumference of, 22 ; closure of 
sutures, 22 ; closure of fontanels, 22 ; 
shape of, 23 ; in rickets, 248 ; exami- 
nation of, 35 ; hydrocephalic, charac- 
teristics of, 772 ; nodding spasm of, 
701. 

Headache, varieties, 709 ; treatment, 710. 

Head-banging, 719. 

Hearing, when developed, 26. 

Heart, diseases of, 575 ; aneurism of, 
612 ; aortic disease, congenital, 581 ; 
auscultation of, 39, 578 ; diphtheritic 
paralysis of, 835 ; examination of, 577 ; 
hypertrophy of, in valvular diseases, 
596 ; in measles, 986 ; in scarlet fever, 
967 ; malformations of, 579 ; peculiari- 
ties of, in early life, 575 ; persistent 
fetal conditions, 580 ; position of apex 
beat, 577 ; in infancy. 577 ; size 
and growth of, 577 ; sounds of redupli- 
cation, 578 ; sudden failure of. in diph- 
theria, 1038 ; thrombus of, ante-mortem, 
612 ; transposition of, 583 ; congen- 
ital anomalies of, 579 ; functional dis- 
turbances of, 608 ; murmurs of, 598 : 
differential diagnosis of, 586 ; acci- 
dental, 606; in congenital discuses. 585 ; 
in chorea, 697; in marasmus, 224; 
valves, aortic insufficiency, 600 ; aortic 
stenosis, 600 ; mitral insufficiency, 599 ; 
mitral stenosis, 599; valvular diseases 
of (see also ENDOCARDITIS), 59 1 : 
chronic valvular disease of. .".07 ; ven- 
tricle, left, signs of dilatation, 599 ; 



signs of hypertrophy, 600 ; right, signs 
of hypertrophy, 599. 

Heart block, in diphtheritic paralysis, 
835. 

Height, 19 ; from birth to sixteenth year, 
20. 

Heliotherapy, in tuberculous peritonitis, 
453. 

Hemichorea, 696. 

Hemiplegia, in acquired cerebral paral- 
ysis, 782 ; in birth paralysis, 779 ; in 
meningeal hemorrhage, 109 ; in cerebral 
tumor, 766 ; spastic, 781. 

Hepatitis, interstitial, 77 ; suppurative. 
439. 

Hermaphroditism, false, 651. 

Hernia, cerebri, 720; diaphragmatic, 119; 
umbilical, 116. 

Herpes labialis, 269. 

Herpetic stomatitis, 277. 

Hiccough, 702 ; in acute peritonitis, 447 ; 
in hysteria, 707. 

Hip-joint disease, 912. 

History-taking, 32. 

Hives (see Urticaria), 933. 

Ilodgkin's disease, 874. 

Holding-breath spells, 681. 

Home modification of milk, 196. 

Hookworm, 429. 

Hutchinson's teeth, in syphilis, 1117. 

Hydatids, of liver, 443. 

Hydrencephalocele, 719. 

Hydrocele, 654. 

Hydrocephalus, 769 ; in chronic basilar 
meningitis, 755 ; with spina bifida, 799, 
801 ; acute (see Meningitis, Tibek- 
CULOCS), 747, 754; chronic external, 
769 ; internal, 770 ; congenital, 723 ; 
intra-uterine, 721 ; syphilitic, 1108. 

Hydronephrosis, 624 : with malforma- 
tions of kidney, 623 ; with renal calculi, 
647. 

Hygiene, of infancy, 1. 

Hyperesthesia, general, in cerebrospinal 
meningitis, 733 ; in acute poliomyelitis, 
811 ; hysterical. 705 ; in multiple neu- 
ritis. 831; in scurvy, 236; in spinal 
meningitis, 802. 

Hypertrophy, muscular pseudo-. 824. 

Hypodermic medication, 66 ; dosage for, 
55. 

Hypodermoclysis, indications for, c><;. 

Hypospadias, 651. 

Hysteria, 705; symptoms, 7(>r» ; diagnosis, 
707 ; treatment, 708. 

Ilv-tero-epilepsy, 707. 

ice bag, 59. 

Ice cap. .".2. 59. 

[ce coil, 59. 

ichthyosis, congenital, 920. 

icterus, 188; in epidemic hemoglobinuria, 
92 ; varieties in newly born, 77; in 
malformation of the bile duets, 7b; 



1170 



INDEX 



interstitial hepatitis. 78 ; physiological 
or idiopathic, 78 ; differential diagnosis, 
81. 

Idiocy, 789 ; Mongolian. 793 ; amaurotic 
family, 788. 

Idiosyncrasies to foodstuffs, 216. 

Ileocolitis, acute, 373 ; catarrhal, 375 ; fol- 
licular, 377 ; membranous, 385 ; associ- 
ated lesions, 381 ; with follicular ulcer- 
ation, 377 ; membranous form, 378 ; 
treatment, 378. et seq. ; bronchopneu- 
monia complicating, 518 ; in diphtheria, 
1037 ; in measles, 985. 

Ileum, congenital atresia of, 118. 

Imbecility, 789. 

Impetigo, bullous, 94 ; in newly born, 94 ; 
contagiosa, 932. 

Inanition, acute, 219. 

Inanition fever, 122. 

Incubators, 12. 

Indican, in urine of chronic constipation, 
404 ; of chronic intestinal indigestion, 
398. 

Indigestion, chronic gastric, 339 ; treat- 
ment, 340 ; acute intestinal, and diar- 
rhea, 357 ; diagnosis, 366 ; treatment, 
367 ; Finkelstein's "food intoxication," 
365. 

Indigestion, chronic intestinal, 395 ; treat- 
ment, 399. 

Infant, care of newly born, 1 ; when 
premature or delicate, 11. 

Infant feeding, 167. 

Infant foods, 165. 

Infantilism, intestinal, 398. 

Infarctions, uric acid, in kidney, 627. 

Infectious diseases, specific, 949. 

Influenza, 1130 ; etiology, 1130 ; lesions, 
1131 ; symptoms, 1132 ; bronchopulmo- 
nary complications. 1155 ; protracted 
cases, 1133 ; complications and sequelae, 
1136 ; anemia in, 1136 ; diagnosis, 1136 ; 
prognosis, 1137 ; treatment, 1137 ; 
bronchopneumonia in, 517, 1134 ; epi- 
demic, acute otitis in, 938 ; scarlatini- 
form erythema in, 970 ; nephritis in, 
1136. 

Inhalations, 62 ; in bronchitis, 484. 

Inheritance, a factor in disease, 30. 

Injections, rectal, in ileocolitis, 388 ; sub- 
cutaneous, of saline solution in cholera 
infantum, 373. 

Intertrigo. 926. 

Intestinal obstruction in newly born, 118 ; 
acute, from intussusception, 410. 

Intestines, diseases of, 348 ; amyloid de- 
generation of, 391 ; bacteria of, 318 ; 
digestion in, 317 ; hemorrhage from, 
in newly born, 104 ; in typhoid, 1063 ; 
in tuberculosis, 393 ; length, 318 ; mal- 
formations of, 348 ; obstruction, con- 
genital of, 118 ; perforation of, in tu- 
berculous ulcers, 393 ; in typhoid fever, 
1063 ; tuberculosis of, 391, 1082 ; eti- 



ology, 392 ; lesions, 392 ; symptoms, 
393 ; treatment, 394. 

Intoxication, acute intestinal and diar- 
rhea, 357 ; etiology, 357 ; lesions, 358 ; 
symptoms, mild form, 359 ; relapses, 
360 ; cases without diarrhea, 362 ; di- 
agnosis, 366 ; prognosis, 366 ; prophy- 
laxis, 366 ; treatment, 367, 372 ; cholera 
infantum, 363 ; treatment, 367 ; acidosis 
in, 372. 

Intubation, in acute catarrhal laryngitis, 
468 ; in syphilitic laryngitis, 474 ; in 
pertussis, 1013. 

Intussusception, 410 ; etiology, 412 ; le- 
sions and mechanism, 412 ; symptoms, 
414 ; diagnosis, 417 ; treatment, 418 ; 
laparotomy, 418 ; in the dying, 411. 

Iodids, elimination of, in milk, 143. 

Iritis, syphilitic, 1109. 

Iron, preparations of, 55. 

Irrigation, intestinal, in chronic indiges- 
tion, 400 ; as antipyretic, 53 ; of the 
colon, method of, 64. 

Ischiorectal abscess, 434. 

Jaundice (see also Icterus), 77; catar- 
rhal, 437. 

Jaw, necrosis of, from alveolar abscess, 
273 ; in gangrenous stomatitis, 286 ; in 
ulcerative stomatitis, 279. 

Jejunum, congenital atresia of, 118. 

Joints, diseases of, 895 ; hysterical af- 
fections of, 706 ; in scarlet fever, 967 : 
rheumatism of, 1150 ; suppuration of. 
in newly born, 85 ; swelling of, in 
scurvy, 236 ; ecchymoses about, in 
scurvy, 235 ; tuberculous diseases of, 
905. 

Junket, 162. 

Kernig's sign, 733. 

Keratitis, interstitial, in late syphilis, 
1109, 1121. 

Kidney, diseases of, 623 ; acute degenera- 
tion of, 628 ; calculi in, 646 ; chronic 
congestion of, 628 ; cystic, 624 ; mov- 
able, 627 ; granular (see Nephritis, 
Chronic), 636; horseshoe, 623; hydro- 
nephrosis, 624 ; malformations and mal- 
positions of, 623 ; malignant tumors of, 
639; nephritis, acute diffuse,' 628; 
acute exudative, 629 ; chronic, 635 ; 
perinephritis, 648 ; pyelitis, 642 ; pyo- 
nephrosis, 645 ; tuberculosis of. 639. 
1081 ; uric-acid infarction in, 627 ; 
in diphtheria, 1027 ; in scarlet fever, 
966. 

Klebs-LoefQer bacillus (see Bacillus op 
Diphtheria), 1020, 1039. 

Knee, articular ostitis of, 916 ; subluxa- 
tion of, in poliomyelitis, 815 ; swelling 
of, in scurvy, 234. 

Knee-jerk, in acquired cerebral paralysis, 
785 ; in birth paralysis, 783 ; lost, in 



INDEX 



1171 



diphtheritic paralysis, 834 ; in multiple j 

neuritis, 831 ; in tetany, G77. 
Knock-knee in rickets, 253. 
Koplik's sign in measles, 978. 
Kumyss, 1G0. 
Kyphosis, in rickets, 251 ; treatment, 258 ; 

in spinal caries, 907. 

Lactalbumin, 138, 183, 

Lactation, care of breasts during. 169. 

Lactic acid milk, 160. 

Lactometer, author's, 139. 

Larynogospasm, 684 ; in rickets, 248 ; 
with tetany, 681. 

Laryngitis, acute catarrhal, 468 ; catar- 
rhal in measles, 984 ; chronic, 472 ; 
with adenoid vegetations of pharynx, 
472 ; tuberculous, 472 ; syphilitic, 473 ; 
with new growths of larynx, 474 ; spas- 
modic, 465 ; submucous (edema of 
glottis), 471. 

Laryngeal diphtheria, 1033 ; antitoxin in. 
1048 ; intubation in, 1053 ; symptoms 
of, 1033. 

Laryngotomy for foreign body in larynx. 
475. 

Larynx, diseases of, 465 ; foreign bodies 
in, 475 ; new growths of, 474 ; spasm 
of, 684. 

Lavage (see Stomach Washing), 62. 

Leukemia, 849. 

Lichen, urticatus (see Urticaria), 934; 
tropicus, 922. 

Lip, eczema of. 2<;9 : perleche. 269; dis- 
eases of, 269 ; herpes of, 269 ; malfor- 
mations of, 267. 

Lisping, 711. 

Liver, diseases of. 436 ; abscess of, 439 ; 
acute yellow atrophy of, 438 ; amyloid 
degeneration of, 441 ; biliary calculi, 
443 ; cirrhosis of, 440 ; congestion of. 
439 ; interstitial hepatitis, 78 ; enlarged 
in congestion, 439 ; in abscess, 439 ; in 
cirrhosis (early), 441; in chronic car- 
diac disease, 593 ; in marasmus, 222 ; 
hydatids of, 443 ; in rickets, 255 : 
in syphilis. 1107, 1022 : in tuberculosis. 
1080 ; lardaceous, 441 ; malformations 
and malpositions of. 437 ; size and posi- 
tion of, 40, 436 ; tuberculosis of, 1080 ; 
waxy, 441 ; weight of, in infancy, 43(5. 

Lumbar puncture, 737. 

Lung, diseases of, 476 ; abscess of, 551 ; 
abscesses of, in acute bronchopneu- 
monia, 505 ; acute congestion of, In 
malaria, 1140; calcareous nodules in. 
1078; caseous degeneration of, 1<»77: 
collapse of, from compression, 553 : 
from obstruction. 554 ; in acute bron- 
chopneumonia, 500; congenital atelec 
tasis of, 74 ; emphysema of, 555 : acute, 
in bronchitis of infants, 482; Ban- 
grene of, 552; gangrene of, in lobar 
pneumonia, 528; hemorrhages into, in 



newly born, 100 ; inflation of, 73 ; 
miliary tuberculosis of, 1084 ; peculiari- 
ties in disease, 478 ; in infancy and 
early childhood, 476 ; physical examina- 
tion of, 477 ; structure of, 477. 

Lymph nodes, diseases of, 862 ; calcareous 
cervical, 869 ; bronchial, 1095 ; early 
infection in tuberculosis, 1072 ; enlarged 
in Hodgkin's disease, 874 ; in malnu- 
trition, 227 ; frequency of disease of, 
41; inflammation of (see Adenitis), 
862 ; in late hereditary syphilis, 1121 ; 
in measles, 986 ; in pseudodiphtheria, 
301 ; in scarlet fever, 964 ; simple hyper- 
plasia of, 865 ; situation and drainage 
areas of the groups of head and neck, 
861 ; syphilitic disease of, 866 ; tubercu- 
lous bronchial, 1078 ; lesions, 1078, 1082 ; 
symptoms, 1031 ; cervical, tuberculosis 
of, 867 ; mesenteric. 393, 1081 ; in 
diphtheria, 1027 ; in rickets, 255 ; in 
tonsillitis, 301 ; epitrochlear, in syphilis, 
1121 ; in typhoid fever, 1060 ; tubercu- 
losis of, 867 ; retropharyngeal, abscess 
of, 290. 

Lymphocytes, 840. 

Malaria, 1139 ; symptoms, 1140 ; treat- 
ment, 1146 ; quinin, methods of admin- 
istration, 1146 ; spleen in. 878. 

Malnutrition, 226. 

Maltose, in infant feeding, 208. 

Malt soup, use of, with difficult feeding 
cases, 185, 208. 

Mania, acute, following typhoid, 1064. 

Marasmus, 221. 

Massage, 66 ; in chronic constipation, 400 ; 
in malnutrition, 230 ; of breasts to 
increase milk, 174. 

Mastitis, in the newly born. 117. 

Mastoid disease, cerebral abscess follow- 
ing. 899 ; in acute otitis, 898. 

Mastoiditis. 942 ; symptoms, 898 ; treat- 
ment, 946 ; dangers from operation, 
946. 

Masturbation. 715. 

Matzoon, 161. 

Measles. 975 ; bronchopneumonia compli- 
cating. 517 : complications and Sequels, 
983 : desquamation. 981 : diagnosis, 
987; digestive system, 985 ; diphtheria 
in, 987 ; duration of Infective period, 
977; ears in. 938, 986; eruption, !»7!) : 
etiology, 975 : eyes in. 986 : German (see 
Rubella), 991; hemorrhage in. 986; 
hemorrhagic, 980; heart in. 986; ileo- 
colitis. 985; Incubation, ".»7<; : Invasion, 
978; kidneys in. 986; larynx in. 98 I : 
lesions. P77 : lungs, 984; lymph nodes. 
986; mode of Infection, 077: mortality. 
988; nervous system in. 986; other in 

fectiollS (lis,;isrs ill. '.1ST ; otitis, 986 ; 

predisposition, 976; prognosis, 988' 
prophylaxis, 989; pseudodiphtheria in, 



1172 



INDEX 



985 ; quarantine in, 989 ; skin in, 986 ; 
symptoms, 978 ; throat, 985 ; treatment, 
989 ; tuberculosis following, 987. 

Meats, from third to sixth year, 212. 

Meckel's diverticulum, 114, 349. 

Meconium, composition of, 319. 

Mediastinum, anterior, abscess of, 1097 ; 
tumor of, due to tuberculous lymph 
nodes, 1096. 

Mediastinitis, 589. 

Melena, 104. 

Meningeal hemorrhage, 102, 724, 779. 

Meninges, diseases of, 719. 

Meningitis, acute, 726 ; cerebrospinal, 
727 ; complications and sequelae, 736 ; 
course, duration and termination, 736 ; 
lesions, 728 ; lumbar puncture in, 737, 
743 ; symptoms, 730, 736 ; diagnosis, 
737 ; prognosis, 736 ; treatment, 738, 
743. 

Meningitis, acute, from other causes than 
the meningococcus, 743 ; pneumococcus, 
744 ; influenza, 745 ; septic, 746 ; in 
newly born, 85 ; from otitis, 943 ; in 
pneumonia, 519, 539. 

Meningitis, chronic basilar, 755 ; spinal, 
802; syphilitic, 1108. 

Meningitis, tuberculous, 747 ; symptoms, 
749 ; diagnosis, 752 ; lumbar puncture 
in, 756. 

Meningocele, of brain, 720 ; of cord, 797. 

Meningo-encephalitis, 780. 

Meningomyelocele, 798. 

Menstruation, effect of, on breast milk, 
142. 

Mental deficiency, 789 ; diagnosis, 790, 
793; treatment, 796. 

Mercury, elimination of, in milk, 143 ; 
ulcerative stomatitis from, 278 ; in 
syphilis, 1128. 

Microcephalus, 722. 

Microorganisms in cow's milk, 145. 

Micturition, difficult or painful, 667 ; 
frequency of, 616. 

Miliaria, 921 ; papulosa, 922 ; treatment, 
927 ; rubra, 922. 

Milk, cow's, 144 ; composition of, 182 ; 
bacteriological standard for, 147 ; 
handling and transportation of, 144, 
145 ; average percentages in, from dif- 
ferent breeds, 148, 149 ; examination 
of, 149 ; cream, 151 ; contaminated, as 
cause of diarrhea, <?52 ; differences from 
woman's milk, 150 ; dried milk, 159 ; 
essentials of, for infant feeding, 144 ; 
formulas from diluting, 187, et seq.; 
formulas reduced to percentages, 191, 
192 ; frozen, 157 ; microorganisms in, 
145 ; modification of, percentage, 187 ; 
at home, 186, 187, 196 ; top-milk, 152 ; 
formulas from whole milk, 187 ; sched- 
ule showing quantities and intervals of 
feeding, 189 ; modifications required by 
particular symptoms, 192 ; in difficult 



cases, 207 ; in summer diarrhea, 368 ; 
in chronic constipation, 405 ; pasteuri- 
zation of, 153, 154, 155 ; pnotein of, 
129; sterilization of, at 212° F., 155; 
tubercle bacilli in, 1020 ; condensed (see 
Condensed Milk), 158; fermented, 
159, 207 ; protein, 161 ; skimmed, 207 ; 
peptonized, 157. 

Milk laboratories, 197. 

Milk-sugar, 132, 184 ; solution, how to 
prepare, 196. 

Milk, woman's, 134 ; physical characters 
of, 134 ; colostrum of, 135 ; daily quan- 
tity of, 135 ; average quantity at one 
nursing, 137 ; composition of, 137 ; pro- 
tein, 137, 138, 140 ; fat, 138 ; sugar, 
138 ; salts, 138 ; reaction, 139 ; specific 
gravity, 139, 141 ; average percentages 
of, 182 ; conditions affecting composi- 
tion of, 141, 144; menstruation, 142; 
diet, 142 ; drugs, 143 ; pregnancy, 143 ; 
elimination of antitoxin and other pro- 
tective substances, 137 ; nervous im- 
pressions, 143 ; examination of, 139 ; 
variations in quality, 141 ; how to mod- 
ify quantity and quality, 174, 175 ; 
indications of scanty supply, 171. 

Modified milk, schedule for feeding from 
birth, 189. 

Mongolian idiocy, 793. 

Monoplegia, in birth paralysis, 781 ; in 
cerebral hemorrhage, 109 ; in cerebral 
tumor, 766. 

Morphin, dosage of, 56 ; dosage in con- 
vulsions, 676 ; hypodermically in cholera 
infantum, 372. 

Mortality, at different ages, 43, 44. 

Mouth, diseases of (see also Stomatitis), 
276, et seq.; care of, at birth, 1, 3; 
hemorrhages from scurvy, 236 ; malfor- 
mations of, 267 ; mucous patches, in 
syphilis, 284 ; "tapir," 826. 

Mouth breathing, with hypertrophy of 
tonsils, 309 ; with adenoids, 297 ; with 
retropharyngeal abscess, 291. 

Mumps, 1015 ; complications and sequelae, 
1018 ; diagnosis, 1019 ; pathology and 
lesions, 1016 ; symptoms, 1017 ; treat- 
ment, 1019. 

Murmurs, cardiac (see Heart Murmurs). 

Muscles, atrophy of, 820 ; in multiple 
neuritis, 831 ; in myelitis, 803 ; in 
poliomyelitis, 815 ; contractures of, 
hysterical, 706 ; in infantile cerebral 
paralysis, 786 ; in birth paralysis, 782 ; 
development of, 25. 

Muscular wasting diseases, different types 
of, 822. 

Muscular pseudohypertrophy, 825. 

Mustard bath, 59 ; paste, 57 ; pack, 58. 

Myelitis, 802 ; symptoms, 803 ; treatment, 
804 ; from Pott's disease, 804 ; diffuse, 
803 ; transverse, 803. 

Myocarditis, 605 ; aneurism in, 605 ; toxic, 



INDEX 



1173 



in diphtheria, 835, 1036 ; in scarlet 
fever, 968 ; in syphilis, 1108. 

Myatonia, congenital (Oppenheim's dis- 
ease), 827. 

Myotonia, congenital (Thomsen's disease), 
702. 

Nail-biting, 718. 

Nails, in syphilis, 1114. 

Neck, cellulitis of, in scarlatina, 964 ; 
congenital fistula of, 311 ; wry- (see 
Torticollis), 703. 

Necrosis, of bone, in syphilis, 1106. 

Nematodes (see Worms), 425. 

Nephritis, acute diffuse, 629 ; etiology, 
629 ; lesions, 629 ; symptoms, 630, 633 ; 
prognosis, 633 ; treatment, 633 ; acute 
parenchymatous type, 630. 

Nephritis, chronic, 635 ; etiology, 635 ; le- 
sions, 636 ; symptoms, 636 ; of the 
parenchymatous type, 636 ; of the in- 
terstitial type, 637 ; diagnosis, 638 ; 
prognosis, 637 ; treatment, 638 ; chronic, 
diffuse, with hydronephrosis, . 625 ; 
chronic interstitial, syphilitic, 1109 ; in 
diphtheria, 1027, 1037 ; interstitial 
(see Nephritis, Chronic), 637; post- 
scarlatinal, 966. 

Nerves, peripheral, diseases of, 828. 

Nervous impressions, effect of, on breast 
milk, 144. 

Nervous system, diseases of, 669 ; general 
hygiene of, 5 ; peculiarities of, in child- 
hood, 669. 

Neuritis, multiple, 828 ; after diphtheria, 
833 ; optic, in acute meningitis, 734 ; in 
cerebral tumor, 767 ; with cerebral ab- 
scess, 761. 

Neuropathic diathesis, 262 ; neuropathic 
child, 264. 

Newly born, diseases of, 69 ; acute in- 
fectious diseases of, 82 ; acute pyogenic 
diseases of, 82 ; atelectasis, congenital, 
74 ; asphyxia of, 69 ; blood in, peculiari- 
ties of, 839 ; diseases or accidents at 
birth, 30 ; facial paralysis in, 110 ; 
fatty degeneration of, 93 ; hemorrhages 
in, 96 ; hemorrhagic diseases of, 101 ; 
hyperpyrexia in, 122 ; icterus in, 77 ; 
infection of, 31 ; malformations of, 30 ; 
mastitis in, 117 ; ophthalmia of, 89 ; 
pemphigus in, 94 ; peritonitis in, 444 ; 
sclerema in. 121 ; skin of, 920 ; ulcer in 
stomach in, 342. 

Night-terrors, 713. 

Nipples, care of, during lactation, 169; 
fissure of, hematemesis from, 346 ; rub- 
ber, choice of, 196; care of, 196. 

Nodes, lymph (see Lymph Nooks), 861. 

Nodules, subcutaneous tendinous, in rheu- 
matism, 1152. 

Noma of face (sec STOMATITIS, GANGRE- 
NOUS), 28S ; of vulva, 662. 

Nose, diseases of, 457 ; deformities of, in 



hereditary syphilis, 463 ; difficulty in 
blowing, with adenoids, 296 ; diphtheria 
of, 1030 ; discharge from, with adenoids, 
296 ; foreign bodies in, 460 ; hemor- 
rhage from, 462 ; in newly born, 1004 ; 
in scurvy, 238 ; in hereditary syphilis, 
462, 1108; in late syphilis, 1122; 
polypi in, 461 ; pseudodiphtheria of, 
301 ; sprays for, 60 ; syringing, 61. 

Nurse, requisite qualities in, 10 ; wet (see 
Wet-Nurse), 176. 

Nursery, general requirements for, 9. 

Nursing, during acute illness, 215 ; dur- 
ing first days of life, 169 ; hours for, 
in newly born, 170 ; during illness, 177 ; 
importance of good habits of, 170 ; un- 
successful, symptoms of, 171 ; maternal, 
contra-indications for, 168. 

Nursing-bottles, choice of, 196 ; care of, 
196. 

Nutrition, derangements of, 218 ; acute 
inanition, 218 ; malnutrition, 226 ; ma- 
rasmus, 221 ; faulty, diseases due to, 
231 ; importance in pediatrics, 127. 

Nystagmus, 701 ; in cerebral hemorrhage, 
109 ; in hydrocephalus, 775 ; in tuber- 
culous meningitis, 750 ; with tumor of 
crura cerebri, 766. 

Oatmeal water, 165. 

O'Dwyer's intubation set, 1053. 

Oil enemata, 65 ; in chronic constipation, 
407. 

Omphalitis, in newly born, 83. 

Omphalomesenteric duct, 115, 349. 

Onychia, syphilitic, 1111. 

Ophthalmia, in newly born, 89. 

Opisthotonus, 7 ; hysterical, 707 ; in cere- 
brospinal meningitis, 731 ; in birth pa- 
ralysis, 782 ; meningeal hemorrhage, 
109 ; in chronic basilar meningitis, 
756 ; in marasmus, 224 ; in tuberculous 
meningitis, 752. 

Opium, elimination of, in milk, 143 ; 
acute intestinal indigestion and di- 
arrhea, 371, 372 ; in bronchitis, 484 ; 
preparations and dosage of, 53. 

Oppenheim's disease, 827. 

Optic v nerve, atrophy of, in cerebral tu- 
mor, 764. 

Orchitis, in mumps, 1018 ; in specific 
urethritis, 653 ; syphilitic, 1109 ; tu- 
berculous, 1082. 

Orthopnea, in chronic valvular disease, 
5!)7 ; in functional disorders of the 
heart. 608. 

Osteogenesis Imperfecta, 895. 

Osteomyelitis, In newly born, 85; tuber- 
culous, '.Us. 

Osteoperiostitis, chronic, syphilitic. 1111. 

ostitis, primary, followed by Jolnl dls 
ease, 906; simulated by scurvy, 288. 

otitis, acute, 938 : etiology, 938 : lesions, 
939; symptoms, 940; complications and 



1174 



INDEX 



sequels?, 942 ; treatment, 944 ; cerebral 
abscess in, 759, 943 ; thrombosis of 
lateral sinus in, 943; facial paralysis 
in, 944 ; labyrinth in, 944 ; mastoid 
disease in, 942 ; meningitis in, 943 ; 
chronic, in late syphilis, 1122 ; in in- 
fluenza, 1139 ; in scarlet fever, 965 ; 
in syphilis, 1109. 

Oxyuris vermicularis (see Worms, Intes- 
tinal), 427. 

Ozena, syphilitic, 463, 1122. 

Pachymeningitis, acute, 723 ; chronic (in- 
ternal), 724; syphilitic, 1108; menin- 
geal hemorrhage from, 725 ; hemor- 
rhagic, 724 ; pseudomembranous, 724. 
Pack, cold, 52 ; hot, 59 ; mustard, 58. 
Palate, cleft, 267 ; diphtheritic paralysis 
of, 833 ; hard, ulceration of, 279 ; in 
late syphilis, 1122 ; soft, lesions of, in 
hereditary syphilis, 463. 

Pancreas, ferments of, 318 ; syphilis of, 
1109 ; tuberculosis of, 1081. 

Paracasein, formed from casein in stom- 
ach digestion, 150. 

Paralysis, atrophic (see Poliomyelitis*, 
806 ; birth, 106, 780 ; atrophy and 
sclerosis following, 780 : meningo- 
encephalitis, 7S0 : secondary degenera- 
tions following, 781 ; symptoms, 781 ; 
Erb's, 111 ; facial, 110, 836 ; in acute 
otitis, 944 ; hysterical, 706 ; in compres- 
sion-myelitis, 805 ; multiple neuritis, 
829 ; in myelitis, 803 ; of face, in newly 
born, 110 ; of the upper extremity in 
newly born, 111; peripheral, 106; (see 
also Neuritis, Multiple), 828; post- 
diphtheritic, 1037 ; pseudohypertrophic, 
824 ; simulated by scurvy, 238. 

Paralysis, infantile cerebral, 106, 779 ; 
acute acquired, 783 ; birth, 780 ; of 
intra-uterine origin, 779 : varieties and 
symptoms, 779, 781, 783 ; prognosis, 
786 ; diagnosis, 787 ; treatment, 787. 

Paralysis, infantile spinal (see Polio- 
myelitis), 806. 

Paraplegia, Pott's (see Myelitis Com- 
pression), 779, 804; spastic, 779. 

Parotitis, epidemic (see Mumps), 1015. 

Pasteurized milk, 154, 155. 

Pathology, general considerations of, 41. 

Pavor nocturnus, 713. 

Peliosis rheumatica, 859. 

Pemphigus, gangrenosa, 932 ; in newly 
born, 94 ; syphilitic, 1110. 

Pepsin, in stomach secretion, 317. 

Peptonized milk, preparation of, 157. 

Percentages, in milk formulas, how to 
calculate them, 191. 

Pericarditis, 588 ; acute in bronchopneu- 
monia, 519 ; chronic, with adhesions, 
593 ; diagnosis, 592 ; dry. 589 ; external, 
589 ; in newly born, 85 ; in rheumatism. 
589, 590, 1151 ; mediastinal, 5 SO ; prog- 



nosis, 591 ; purulent, 589 ; serofibrin- 
ous, 589 ; tuberculous, 589 ; with effu- 
sion, 589 ; with effusion of blood, 589 ; 
with lobar pneumonia, 529 ; with pleu- 
ropneumonia, 545 ; with transudation 
of serum, 588. 

Pericardium, congenital absence of, 582 ; 
tuberculosis of, 1080. 

Perinephritis, 648 ; acute peritonitis com- 
plicating, 445. 

Peritoneum, diseases of, 444 ; hemorrhage 
into, in newly born, 101 ; in tubercu- 
losis, 1081. 

Peritonitis, acute, 4*4 ; etiology, 444 ; le- 
sions, 445 ; symptoms, 446 ; treatment, 
447 ; chronic, non-tuberculous, 448 ; 
with ascites, 448 ; fetal, cause of mal- 
formations, 349 ; in intussusception, 
417 ; in newly born, 84 ; in suppurative 
appendicitis, 419 ; pelvic from gonor- 
rhea, 658 ; tuberculous, 449 ; miliary, 
with general tuberculosis, 450 ; with 
ascites, 450 ; fibrous form, 451 ; with 
intestinal ulcers, 393 ; with lobar pneu- 
monia, 539. 

Pertussis, 1003 ; bronchopneumonia in, 

1008 ; complications, 1008 ; convulsions, 

1009 ; diagnosis, 1010 ; etiology, 1004 ; 
hemorrhages in, 1008 ; ileocolitis in, 
1009 ; incubation, 1005 ; infective pe- 
riod, 1009 ; lesions, 1005 ; leukocytosis 
in. 1011 ; paralysis in, 1009 ; predispo- 
sition to, 1004 ; prognosis, 1011 ; pro- 
phylaxis, 1012 ; symptoms, 1006 ; treat- 
ment, 1012, 1015 ; vaccines in, 1014. 

Peyer's patches, in typhoid fever, 1060 ; 
swollen, in acute ileocolitis, 359 ; tu- 
berculosis of, 393 ; ulceration of, in 
ileocolitis, 379. 

Pharyngitis, acute. 288 ; uvulitis in, 289 ; 
chronic catarrhal, syphilitic, 1108. 

Pharynx, diseases of, 288 ; adenoid veg- 
etations of vault, 296 ; with adenitis, 
862; diphtheria of, 1024; diphtheritic 
paralysis of, 834 ; lesions of, in heredi- 
tary syphilis, 463 ; retropharyngeal ab- 
scess, 290 ; syphilitic ulceration of, 
1108 ; syringing of, 61. 

Phimosis, 650. 

Phlebitis, of dural sinuses, 757. 

Phosphorus, in rickets, 259. 

Phthisis, chronic, 1078, 1095. 

Physical examination, of the child, 34. 

Pica, 719. 

Pinworms (see Worms, Intestinal), 
427 ; proctitis from, 432. 

Pleura, effusion into, in acute nephritis, 
632; tuberculosis of, 1075, 1080. 

Pleurisy, 557 : dry, 558 ; in acute bron- 
chopneumonia, 504 ; purulent (see 
Empyema), 563; tuberculous, dry form, 
558 ; with lobar pneumonia, 528 ; with 
serous effusion, 560 ; Grocco's sign in, 
561. 



INDEX 



1175 



Pleuropneumonia, 544 ; pericarditis in, 
588, 590. 

Fneurnococcus, in bronchopneumonia, 
495 ; lobar pneumonia, 495 ; peri- 
tonitis, 445 ; diphtheria, 1023, 1035 ; 
empyema, 563 ; acute meningitis, 744 ; 
malignant endocarditis, (504 ; pericar- 
ditis, 588. 

Pneumonia, 492 ; anatomical varieties and 
classifications of, 493 ; broncho (see 
Bronchopneumonia, Acute), 497; 
catarrhal (see Bronchopneumonia, 
Acute), 497; chronic interstitial (see 
Bronchopneumonia, Chronic), 547; 
in newly born, 84 ; in typhoid fever, 
1063 ; sources of infection, 496 ; varie- 
ties, classification of, 495 ; hyperacute, 
524 ; hypostatic, 547 ; lobular (see 
Bronchopneumonia, Acute), 497; 
pleuro (see Pleuropneumonia), 544; 
syphilitic, 1107 ; tuberculous, 1080 ; 
course, duration, termination, 1087, 
1088 ; diagnosis, 1094 ; physical signs, 
1092 ; chronic, 1093. 

Pneumonia, lobar, 526 ; etiology, 526 ; fre- 
quency of, 495, 526 ; complicating in- 
fluenza, 1133 ; complications. 539 ; 
course, 539 ; abortive, 530 ; cerebral, 
531 ; diagnosis, 540 ; lesions, 527 ; lysis, 
frequency of, 533 ; pathological differ- 
entiation from bronchopneumonia, 540 ; 
physical signs, 535 ; prognosis, 542 ; 
symptoms, 529 ; termination, 539 ; treat- 
ment, 543. 

Pneumothorax, in pulmonary tuberculosis, 
1080. 

Poisons, gastritis from, 336, 338. 

Poisoning, stomach washing, in, 63. 

Poliencephalitis, acute, causing cerebral 
paralysis, 785. 

Poliomyelitis, acute, 806 ; et'.ology, 807 ; 
diagnosis, 816 ; extent and distribu- 
tion of primary paralysis, 813 ; elec- 
trical reactions, 815 ; lesions, 808 ; prog- 
nosis, 817 ; symptoms, 810 ; treatment, 
818. 

Polydipsia, in diabetes Insipidus, 021 ; 
mellitus, 1156. 

Polypi, nasal. 4<>1 ; rectal, 435. 

Polyuria, <J21 ; hysterical, 707 ; in dia- 
betes insipidus, (121 ; in diabetes melli- 
tus, 1156. 

Porencephalia, 723. 

Pott's disease (see Spine, Caries of), 
907. 

Precordia, bulging of, 577, 600. 

Pregnancy, effect of, on woman's milk, 
143; effect of, on nursing child, 
178. 

Premature infants, management of, 11. 

Prepuce, adherent, 650. 

Prickly beat, 922. 

Proctitis, 432. 

Prognosis, general consideration of, 43. 



Progressive muscular wasting diseas< s, 
the Werdig-Hoffman type, 822 ; peron- 
eal type, 823. 

Prolapsus ani (see also Rectum, Pro- 
lapse of), 430; from proctitis, 433; 
in ileocolitis, 382 ; in membranous ileo- 
colitis, 385. 

Prophylaxis, general consideration of, 50. 

Protein, determination of. in milk, 140 ; 
function in diet, 129 ; in the feces, 
320 ; of woman's milk, 131 ; of cow's 
milk, 148 ; percentages of, in modifi- 
cation of cow's milk, 191. 

Protein milk, 101. 

Pseudodiphtheria (see Membranous Ton- 
sillitis), 300. 

Pseudohypertrophic paralysis, 824. 

Pseudoparalysis in rickets, 257 ; in scurvy, 
235 ; in syphilis, 1114. 

Puberty, delayed, in cretins, 884 ; in syph- 
ilis, 1123; effect of, on heart, in val- 
vular disease, 597, 601. 

Pulse, examination of, 36 ; in early life, 
576. 

Purpura, 854 ; arthritic, 859 ; blood in, 

856 ; fulminans, 858 ; gangrenous, 858 ; 
hematemesis ip, 857 ; hemorrhagica, 

857 ; Henoch's, 857 ; primary, 855 ; 
rheumatica, 859 ; simplex, 854 ; symp- 
tomatic, 854 ; cachectic, 854 ; infec- 
tious, 854 ; neurotic, 855 ; mechanical, 
855 ; toxic, 854. 

Pyemia, in newly born, 82 ; of bone (see 
Arthritis, Acute), 850. 

Pyelitis, 642. 

Pyelocystitis, 642. 

Pyelonephritis, 620. 

Pylephlebitis, 439 ; cause of hepatic ab- 
scess, 439. 

Pylorus, hypertrophic stenosis of, 321 ; 
diagnosis, 325 ; treatment, 326. 

Pyogenic diseases, acute, in newly born, 
82 ; general symptoms, 87 ; prophylaxis, 
8(1 ; treatment, 88. 

Pyonephrosis, following pyelitis. 642. 

Pyopneumothorax, in pulmonary tubercu- 
losis, 10SO. 

Pyuria, 620; in pyelitis, 642. 

Quinin, dosage, 1147; methods of admin- 
istration, 1147; scarlatiniforra rash. 
970. 

Quinsy, 307. 

Rachitis (see RlCKBTS), 243. 

Reaction, of degeneration, in ECrb's paral- 
ysis. Ml',; in facial paralysis, 111; in 
multiple neuritis. 831 | in poliomyelitis. 
Sir.. M7. 

Rectal injections (see EjNEMATA), (',."»; as- 
tringent. 380 : oil. 407 ; saline, 389. 

Rectal polypus, 135. 

Rectum, diseases of, 130 ; administration 
of drugs i»y. 66; atresia of, 348; con 



3176 



INDEX 



genital obstruction of. 118 ; feeding by, 
66 ; hemorrhage from ulcers of, 433 ; 
inflammation of (see Proctitis), 432; 
malformations of, 348 ; prolapse of, 
430 ; ulcers of, 433. 

Regurgitation of food, causes of, in 
young infants, 193 ; nasal, in diph- 
theria, 834, 1031, 1039. 

Remittent fever, malarial, 1142. 

Renal calculi, 646 ; renal colic, 647. 

Rennet ferment in digestion, 317. 

Respiration, artificial, methods of, 71, 
72 ; Cheyne-Stokes, in cerebrospinal 
meningitis, 734 ; in meningitis, tuber- 
culous, 750 ; paralysis of, in diphtheria, 
834 ; rapidity and characteristics of, 
476. 

Respiratory system, diseases of, 457. 

Rheumatism, 1149 ; diagnosis, 1153 ; treat- 
ment, 1154 ; chorea in, 694, 1152 ; en- 
docarditis in, 595, 1151 ; erythema in, 
1153 ; purpura in, 859, 1153 ; scar- 
latinal, 967 ; simulated by scurvy, 
238 ; subcutaneous tendinous nodules, 
1152 ; tonsillitis in, 306, 1152 ; torticol- 
lis in, 703, 1152. 

Rhinitis, chronic, 461 ; hypertrophic, 
cause of asthma, 488 ; simple, 461 ; 
syphilitic, 462. 

Rhinopharyngitis, acute, 457 ; in influ- 
enza, 1131 ; with adenoids, 296. 

Rhinopharynx, diphtheria of, 1025 ; sim- 
ple catarrh of, in acute otitis, 939. 

Ribs, beading of, early symptoms in rick- 
ets, 250 ; resection of, in empyema, 571. 

Rice water, 165. 

Rickets, 240 ; etiology, 241 ; lesions, 244 ; 
symptoms, 248 ; calcium metabolism in, 
256 ; course and termination, 256 ; 
acute, 256 (see also Scorbutus), 232; 
congenital, 256 ; convulsions in, 255 ; 
nervous symptoms of, 255 ; diagnosis, 
256 ; from scurvy, 238, 257 ; prognosis, 
258 ; treatment, 258 ; of deformities, 
252 ; late, 256 ; spleen in, 246, 877. 

Ringworm of scalp, 936. 

Rotheln (see Rubella), 991. 

Roundworms (see Worms, Intestinal), 
425. 

Rubella, 991 ; eruption, 992 ; treatment, 
994. 

Rubeola (see Measles), 975. 

Rumination, 330. 

Saccharomyces albicans, in thrush, 281. 

Saline solution, as rectal injection, 389 ; 
subcutaneous injection of, in cholera in- 
fantum, 372 ; in acute inanition, 221. 

Saliva, 315. 

Salivation, in mumps, 1017 ; in ulcerative 
stomatitis, 279. 

Salvarsan, 1129. 

Salts, inorganic, in modification of cow's 
milk, 186 ; mineral, function of, in 



diet, 132 ; of cow's milk, 150 ; of 
woman's milk, 138. 

Sarcoma, of brain, 762 ; of kidney, 641 ; 
of spinal cord, 819 ; of stomach, 345. 

Scabies, 935. 

Scalp, pustular eczema of, 926 ; ring- 
worm of, 936 ; seborrhea of, 923. 

Scarlatina (see Scarlet Fever), 952. 

Scarlatiniform erythema, causes of, 970. 

Scarlet fever, 952 ; albuminuria in, 966 ; 
angina in, 963 ; blood in, 963 ; cellulitis 
in, 964 ; complications and sequela?, 
963 ; desquamation, 957 ; diagnosis, 
969 ; diphtheria in, 963, 969 ; duration 
of infective period, 954 ; eruption, 956 ; 
etiology, 952 ; heart in, 919 ; incuba- 
tion of, 953 ; invasion, 955 ; joints in, 
967 ; kidneys in, 966 ; lesions, 955 ; 
lymph nodes in, 964 ; mode of infec- 
tion, 954 ; mortality in, 971 ; myocar- 
ditis in, 967 ; nervous system in, 969 ; 
other infectious diseases with, 969 ; 
otitis in, 965 ; predisposition to, 953 ; 
prognosis, 971 ; prophylaxis, 971 ; quar- 
antine in, 971 ; relapses, recurrences 
and second attacks, 962 ; symptoms, 
955, 963 ; surgical, 962 ; throat in, 963 ; 
treatment, 972. 

Sclerema, 121 ; in cholera infantum, 365. 

Scorbutus, 231 ; etiology, 232 ; lesions, 
235 ; symptoms, 234 ; diagnosis, 238 ; 
treatment, 239 ; rickets with, 238 ; 
stomatitis in, 280. 

Scrofula (see Adenitis, Tuberculous), 
867; (see Tuberculosis), 1067. 

Scurvy (see Scorbutus), 231. 

Seborrhea, 923. 

Senses, special, development of, 26. 

Sepsis, in newly born, 82. 

Serum-therapy of diphtheria, 1047. 

Serum-therapy of cerebrospinal meningi- 
tis, 939. 

Shiga bacillus (see Bacillus of Dysen- 
tery), 357, 374. 

Shower bath, 57. 

Sight, when developed, 25. 

Singultus, 702. 

Sinuses of dura mater, thrombosis of, 
757 ; lateral, in otitis, 943. 

Skin, diseases of, 920 ; of newly born, 
920 ; care of, in newly born, 4. 

Skull, asymmetry of, in birth paralysis, 
780 ; in rickets, 249 ; sutures, syphilitic 
nodes on, 1118. 

Sleep, disorders of, 712 ; disturbed, 7, 
713 ; with hypertrophy of tonsils, 309 ; 
in intestinal indigestion, 397 ; in rick- 
ets, 248 ; with adenoids, 296 ; exces- 
sive, 714 ; inspection during, 33 ; proper 
periods of, 5. 

Sleeplessness. 712. 

Smallpox, protection against (see Vacci- 
nation), 997. 

Smell, sense of, when developed, 27. 



INDEX 



1177 



Snuffles, syphilitic, 462, 1110. 

Spasm, carpopedal (see Tetany), 677; of 
larynx, 981 ; habit, 700 ; nodding, of 
the head, 701 ; rotary, of the head, 
701. 

Speech, disorders of, 710 ; when acquired, 
27. 

Spina bifida, 793 ; with congenital hydro- 
cephalus, 773. 

Spinal cord (see Cord, Spinal), 796. 

Spine, angular curvature of, in caries, 
910 ; caries of, 907 ; physical examina- 
tion, 909 ; causing compression of cord. 
804 ; curvature of, in hip disease, 915 ; 
hysterical affections, referable to, 706 ; 
in rickets. 252 ; lateral deviation of, 
911 ; Pott's disease of (see Spine, 
Caries of), 907. 

Spirocheta pallida, in syphilis. 1103. 

Spleen, diseases of, 876 ; Banti's disease, 
878 ; amyloid degeneration of, 878 ; en- 
largement of, 877 ; in acute disease, 
877 ; in chronic cardiac disease, 593 ; 
in chronic disease, 878 ; in cirrhosis of 
liver, 441 ; in leukemia, 849 ; in ma- 
laria, 1143 ; in pseudoleukemic anemia, 
844; in rickets, 246, 878; in second- 
ary anemia, 842 ; in typhoid fever, 
1061 ; with amyloid liver, 441 ; in diph- 
theria, 1061 ; in hereditary syphilis. 
1107 ; in late syphilis, 1122 ; in tuber- 
culosis, 1091 ; new growths and tu- 
mors of, 878 ; position and methods 
of examination, 877 ; weight, 876. 

Sprue (see Thrush), 282. 

Sputum, means of obtaining, for exami- 
nation, 1095. 

Stammering, 711. 

Staphylococcus, in furunculosis, 931 ; in 
acute bronchopneumonia, 496 ; in diph- 
theria, 1023 ; in empyema, 563. 

Starch, objections to, as food of young 
infants, 132. 

Status lymphaticus, 49, 891. 

Stenosis. laryngeal, in acute catarrhal 
laryngitis, 469 ; in syphilitic, 473 ; of 
pylorus, 321 ; dilated stomach in. 341. 

Sterilization of milk, 152 ; changes pro- 
duced by, 152; at 212° V.. 15.V. at low 
temperature, 153 : indications for, 154 ; 
limitations of, 154; methods of, 155. 

Still's disease. 902. 

Stimulants, 54. 

Stomach, diseases of. 315; absorption 
from, 318; bacteria of, 318; conges- 
tion of. in acute intestinal Indigestion 
and diarrhea. 358; digestion in. .".15; 
dilatation of. 304; in chronic gastric 
Indigestion, ■';■':'.»; in rickets, 25 1 ; 1m in 

orrhage from, 345; In newly born, 104; 

in scurvy, 238; Inflai atlon of (see 

Gastritis), 835; malformations and 

malpositions of, 323 ; ulcer of, in 

chlorosis, 844; tuberculosis of, 1081; 



tumors of, 345 ; ulcer of, 342 ; in newly 
born, 342 ; from acute gastritis, 342 ; 
tuberculous, 337 ; simple, perforating, 
343. 

Stomach washing, 62 ; indications for, 
63. 

Stomatitis, aphthous (see Herpetic 
Stomatitis), 277; catarrhal, 276; 
diphtheritic, 285, 1026; follicular (see 
Herpetic Stomatitis), 277; gangre- 
nous. 285 ; gonorrheal, 284 ; herpetic, 
277 ; in newly born, 84 ; parasitic (see 
Thrush), 281; syphilitic. 284; ulcer- 
ative, 278 ; vesicular (see Herpetic 
Stomatitis), 277. 

Stone, in the kidney, 646 ; in the bladder, 
647. 

Stools, blood in, from ulcer of stomach, 
344 ; in catarrhal ileocolitis, 382, 384 ; 
in membraneous ileocolitis, 385 ; in in- 
tussusception. 416 ; in purpura, 857 ; 
fat in, 194, 360 ; green, explanation of, 
360 ; in acute intestinal indigestion 
and diarrhea, 360 ; in cholera infan- 
tum, 363 ; in acute ileocolitis, 374, 376, 
381, 382 ; indication of improper feed- 
ing, 192, 193 ; mucus in, in malnutri- 
tion, 224. 

Strabismus, with tumor of crura cerebri. 
766. 

Streptococcus, angina (see Membranous 
Tonsillitis), 300; pyogenes, in acute 
bronchopneumonia, 495 ; in complica- 
tions of scarlet fever, 963 ; in derma- 
titis gangrenosa, 932; in diphtheria. 
1023, 1027, 1035 ; in empyema, 563 ; in 
measles, 984 ; in peritonitis, acute, 445 ; 
in pseudodiphtheria, 301 ; in scarlet 
fever, 952. 

Stridor, in catarrhal spasm of larynx, 
4H7 ; in acute catarrhal laryngitis, 469; 
congenital. 120. 

Strophulus (see Miliaria Rubra), 922; 
(see Urticaria), 934. 

Stuttering, 710. 

Sucking, 315 ; as a bad habit, 714. 

Sudamina, 921. 

Sudden death, chief causes of. 48, 49. 

Sugar, cane, derivatives in digestion. 
318; substitute for milk sugar. 132. 
182, 185; milk, determination of. 140; 
percentage of. in woman's milk. 182 ; 
milk, derivatives in digestion, 318; 
percentages of. in modification of cow's 
milk. 1M ; solutions, rules tor making, 
191, 192; stools in. difficult digestion 
of. :;»;'.• ; symptoms of excess of, in 
food, 203, 2oi. 207. 

Summer diarrhea, .".57. 

Suppositories, in chronic constipation, 
107 ; proctitis from ion- use of glycerin, 
132. 

Suprarenal capsules, in Byphilis, 1109; in 
tuberculosis, 1082. 



1178 



INDEX 



Sutures, closure of, 22; premature ossi- 
fication of, 24. 

Swallowing, of foreign bodies, 346. 

Sweating, in infants, 920 ; of head in 
rickets, 248 ; in tuberculosis, 1090. 

Symptomatology, general considerations 
of, 31. 

Synovitis, acute purulent (see Arthritis, 
Acute), 900; scarlatinal, 967. 

Syphilis, 1103 ; acute osteomyelitis in, 
1106 ; bone lesions in, 1106 ; chronic 
osteoperiostitis in, 1114 ; dactylitis in, 
1115 ; of larynx, 473 ; pseudoparalysis 
in, 1114 ; spleen in, 878 ; acquired, 
1103. 

Syphilis, hereditary, 1104 ; adenitis in, 
866 : bones, 1106 ; Colles' law, 1105 ; 
communicability of, 1105 ; diagnosis, 
1124 ; etiology. 1104 ; evidences of, in 
fetus, 1106 ; hemorrhages, 1113 ; le- 
sions. 1105 ; prognosis, 1125 ; prophy- 
laxis. 1127 ; pseudoparalysis, 1114 ; 
rhinitis of, 462 ; spleen, 1107 ; symp- 
toms, 1109 ; at birth, 1109 ; treatment, 
1128 ; salvarsan, 1129 ; late hereditary, 
1125 ; bones, 1128 ; skin, 1122 ; liver, 
1107 ; nervous system, 1123 ; spleen, 
1107 ; teeth, 1117 ; tertiary, chronic 
laryngitis in, 473 ; intubation for, 474. 

Syringe, nasal, 61. 

Syringing, nasal, 61 ; of mouth and 
pharynx, 61. 

Syringomyelocele, 799. 



Tachycardia, 608. 

Tenia, cucumerina or elliptica, 423 ; nana, 
424 ; saginata or mediocarnellata, 423 ; 
solium, 423. 

Tapeworms, 423. 

Taste, when developed, 27. 

Teeth, 28 ; eruption of first set, 28 ; per- 
manent set, 29 ; care of, 3 ; decayed 
(see Dental Caries), 272; cause of 
adenitis, 862 ; delayed, in rickets, 254 ; 
Hutchinson's, in syphilis, 1118. 

Temperature, at birth, 36 ; in childhood, 
36 ; subnormal, 37 ; raised by artificial 
heat, 37 ; variations of, in health, 36 ; 
of nursery, 9. 

Tenesmus, from proctitis. 433 ; in intus- 
susception, 416 ; in membranous ileo- 
colitis. 381 ; treatment of, 434. 

Testicle, retraction of, with renal calculi, 
647 ; syphilis of, 1107 ; undescended, 
652. 

Tetanus, in the newly born, 90. 

Tetany, 677. 

Therapeutics, general consideration of, 51. 

Thomsen's disease, 702. 

Thoraplasty, 573. 

Thorax, description of, 476 ; measure- 
ments of, 20, 24 ; causes of deformity of, 
24. 



Threadworms (see Worms, Intestinal), 
427. 

Throat, diseases of (see Pharynx and 
Tonsils), 288, 300. 

Thrombosis, 612 ; cachectic, of dural 
sinuses, 757 ; in diphtheria, 1028, 
1036 ; in infectious diseases, 613 ; in- 
flammatory, of dural sinuses, 757 ; of 
internal jugular vein, 613 ; of lateral 
sinus in acute otitis, 943 ; of sinuses 
of dura mater, 758 ; of the aorta, 613 ; 
of the vena cava, 613 ; septic, of dural 
sinuses, 758. 

Thrush, 281. 

Thymus, enlargement of. causing convul- 
sions, 49 ; in status lymphaticus, 891 ; 
tuberculosis of, 1081. 

Thyroid extract in cretinism, 887. 

Thyroid gland, congenital absence of, in 
cretinism, 882. 

Tibia, deformities of. in rickets, 253 ; 
sabre-blade deformity in syphilis, 1121. 

Tinea tonsurans, 936 ; treatment, 937. 

Toes, clubbing of, in congenital heart dis- 
ease, 583. 

Tongue, diseases of, 269 ; congenital hy- 
pertrophy of, 268 ; epithelial desquama- 
tion of, 269 ; geographical, 270 ; inflam- 
mation of, 270 ; malformations of, 267 ; 
ulcer of frenum, 271. 

Tongue-sucking, 718. 

Tongue-swallowing, 271. 

Tongue-tie, 268. 

Tonics, 54. 

Tonsils, diseases of, 300 ; anatomy of, 
300 ; chronic hypertrophy of, 308 ; diph- 
theria of, 1024, 1029 ; hypertrophy of, 
cause of asthma, 488 ; hypertrophy of, 
in rickets, 255 ; removal advised in tu- 
berculous adenitis. 872 ; with adenitis, 
865 ; membrane upon, in scarlet fever, 
963. 

Tonsillitis. membranous (pseudodiph- 
theria ; streptococcus angina ; croupous 
tonsillitis), 300: diagnosis. 303; prog- 
nosis, 303 ; treatment. 304 ; broncho- 
pneumonia in, 302 ; follicular, 305 ; di- 
agnosis, 306 ; treatment, 306 ; in rheu- 
matism, 1152 ; phlegmonous, 307 ; ul- 
ceromembranous (Vincent's angina), 
304. 

Tonsillotomy. 310. 

Top-milk. 152. 

Torticollis. 703 : congenital. 703 : from 
cervical Pott's disease, 703, 908 ; from 
hematoma of sternomastoid. 97 ; hys- 
terical, 707 ; in phlegmonous tonsillitis, 
307 ; in retropharyngeal abscess, 303 ; 
rheumatic, 307 ; spasmodic, 704. 

Touch, when developed, 26. 

Toxemia. in intestinal indigestior, 
chronic, 397 ; vomiting in, 329 ; in acute 
gastric indigestion, 329. 

Tracheotomy, for foreign body in larynx, 



INDEX 



1179 



475 : in laryngeal diphtheria. 1058 : in 
retroesophageal abscess, 314. 

Transfusion, of blood. 68. 

Trousseau's sign, in Tetany, 082. 

Trypsin, 310. 

Tubercle bacilli (see Bacillus of Tu- 
berculosis), 1071. 

Tuberculin test in herds, 145 ; in diag- 
nosis, 1099. 

Tuberculosis, 1067 ; age. 1067 ; bacillus 
of (see Bacillus op Tuberculosis), 
1067 ; in milk, 145 ; bronchial lymph 
nodes in, 1095 ; clinical forms of, 1082 ; 
bronchopneumonia, 1075, 1086 ; chronic 
phthisis, 1095 ; chronic pulmonary, 
1084 ; congenital, 1069 ; diagnosis of 
pulmonary, 1094 ; of bronchial glands, 
1078; general, 1082; etiology, 1082; 
following measles, 987 ; following per- 
tussis, 1012 ; frequency, 1067 ; general, 
in infants, 1082 ; in older children, 
1082 ; hemoptysis, 1039 ; incipient, 
symptoms in, 1082 ; intestines, 391, 
1081 ; intra-uterine infection, 1069 ; 
kidney. 639. 1081 ; lesions, 1073 ; mesen- 
teric, 391 ; miliary, of the lungs, 1084 ; 
mode of infection, 1069 ; of larynx, 
472 ; of lympb nodes, cervical, 867 ; of 
the skin, 1100 ; paths of infection, 
1072; pericarditis in, 588; physical 
signs, 1092 ; pleura in, 559, 1080 ; pre- 
disposing causes. 1009 ; prognosis, 
1101; prophylaxis, 1101; spleen, 1081; 
sputum, means of obtaining, 1095 ; 
treatment, 1102 ; tuberculin tests, 
1099. 

Tuberculous adenitis. 867 ; bronchial 
glands, 1078, 1095. 1098; meningitis, 
747 : nephritis, 639 ; ostitis, 905 ; peri- 
carditis, 580; peritonitis, 449; pleu- 
risy. 559 : pneumonia, 1086, 1092. 

Tumor, abdominal, in intussusception. 
415: in stenosis of pylorus, 324; cere- 
bral, 762 ; pituitary, 767 ; tuberculous, 
1080, 1081; fatty, in cretinism. 884; 
of spinal cord, 819; mediastinal tu- 
berculous lymph nodes, 1097 ; of spleen, 
878, 1107. 

Tunica vaginalis, hydrocele of, 654. 

Turpentine stupe, preparation of, 58. 

Tympanites in acute peritonitis, 446; in 
intestinal Indigestion, 396 : in rickets, 
254 : in typhoid fever, 1061. 

Typhoid fever, 1058; bacillus of. in milk, 
146; complications and sequels, 1063; 
diagnosis. 1064; etiology. 1007; le- 
sions, 1060; prognosis, 1065; scarlatini- 
t'orm erythema in. 970 : symptoms, 
1000; treatment, 1066; paratyphoid. 
1058 : fetal. 1058; infantile 1058. 

riccromembranous tonsillitis, :'.'»! 
L'lcers, catarrhal, of Intestine, ::77 ; fol 
licular, of intestine, .'177 ; following tu 



berculous adenitis. 870 ; of stomach, 
342. 1081 ; tuberculous, of bronchial 
lymph nodes, 1097 ; tuberculous, of in- 
testine, 391 ; tuberculous, of skin, 870 ; 
syphilitic, 1122 ; typhoid, 1060. 

Umbilical vessels, arteritis, in newly 
born, 83 ; phlebitis, in newly born, 82 ; 
fistula, 115. 

Umbilicus, hemorrhage from, in newly 
born, 103 ; hernia of, 116 ; inflamma- 
tion of vessels, in newly born. 83 ; tu- 
mors of, 115. 

Uremia, acute, in scarlet fever, 969 ; in 
acute nephritis, 631 ; in chronic nephri- 
tis, 637. 

Urethra, hemorrhage from, in newly born, 
105. 

Urethritis, 653 ; gonorrheal, 653. 

Uric acid, in early infancy, 616 ; infarc- 
tions, in kidney, 627 ; causing hema- 
turia, 105. 

Urine, arrest of secretion (see Anuria), 
621 ; albumin in, 617 ; blood in (see 
Hematuria), 619; composition of, 616; 
daily quantity of, 615 ; examination of, 
41 ; hyperacidity of, in rheumatism. 
1155 ; incontinence of, 662 ; with ade- 
noids, 291 ; in diabetes, 1091 ; retention 
of, in myelitis, 779; in typhoid, -*1013 ; 
in vesical calculus, 667 ; in infancy and 
childhood, 615 ; methods of collecting. 
41, 615 ; microscopical examination of, 
616 ; physical character of, 616 ; pus in 
(see Pyuria), 620; reaction of, 616; 
specific gravity of, 616 ; sugar in, 617 ; 
uric acid in, 616. 

Urogenital organs, tuberculosis of, 1081. 

Urogenital system, diseases of, 615. 

Urticaria, 933 ; following diphtheria anti- 
toxin, 1050 ; in intestinal indigestion. 
397 ; papulosa, 934 ; scarlatiniform 
rash with, 970. 

Uvula, bifid, 268 ; diphtheria of, 1024 ; 
elongation of, 289 ; cause of asthma, 
488; edema of, 289; Inflammation of, 
289. 

Vaccination, 997 ; choice of lymph, 

997 ; methods of. 999 ; revaccination, 

997. 
Vaccinia, 997. 
Vaccines, 57. 
Vaginitis, 655 ; simple, <'»."»r> ; gonoCOCCUS, 

or,7. 
Vapor bath. 59. 
Varicella, 994 ; symptoms, 995 ; diagnosis, 

996; gangrenosa, 932, 995; treatment, 

996. 
Vegetables, third to sixth year. 212. 
Veins, internal Jugular, thrombosis of, 

613 : umbilical, 575. 
Veins, abdominal, dilated, in cirrhosis ,,f 

liver, 441 ; in thrombosis of vena cava, 

618. 



1 1 so 



INDEX 



Ventricles, cardiac, relative thickness of, 
577. 

Vertigo, in cerebral abscess, 760; in 
cerebral tumor, 704 ; in functional dis- 
turbances of the heart, 608. 

Vesical calculi, 667. 

Vincent's angina (see Ulcero-Membra- 
nous Tonsillitis), 304. 

Viscera, abdominal, transposition of, 
350 ; frequency of inflammations of, 
42 ; hemorrhages of, in newly born, 
101 ; vitamins, 233. 

Voice, hoarse or husky, with adenoids, 
297 ; nasal, with hypertrophy of ton- 
sils, 309; with adenoids, 296; in diph- 
theritic paralysis, 834. 

Volvulus, fetal cause of malformations, 
349. 

Vomiting, 329, 331 ; from overfilling the 
stomach, 329 ; in acute gastric indiges- 
tion, 329 ; in hypertrophic stenosis of 
pylorus, 322-; in acute intestinal ob- 
struction, 329 ; in peritonitis, 329 ; in 
nervous diseases, 329 ; at onset of acute 
febrile disease, 330 ; from toxic sub- 
stances in the blood, 330 ; reflex, 330 ; 
from habit, 330 ; chronic, 331 ; of blood, 
in ulcer of stomach, 343 ; stercoraceous, 
in intussusception, 414 ; cyclic, 331 ; 
treatment, 334. 

von Pirquet's test for tuberculosis, 1099. 

Vulvitis, gangrenous, 662. 



Walking, causes which prevent, 25 ; de- 
layed, in rickets, 255 ; when attempted, 
25. 

Wasting, in tuberculosis, 1090 ; simple 
(see Marasmus), 221. 

Water, function of, in diet, 133. 



Weaning, 177 ; time for, 177 ; indica- 
tions for, 178 ; sudden, 177. 

Weather, hot, prophylaxis against diar- 
rhea in, 366. 

Weight, 15 ; at birth, 16 ; curve during 
first few weeks, 16 ; curve of first year, 
17 ; from second to fifth year, 18 ; of 
older children, 19 ; from birth to six- 
teenth year, 20 ; loss of, in acute inani- 
tion, 219 ; stationary, indications, 195 ; 
symptoms of unsuccessful nursing, 171, 
et seq. 

Werlhof's disease (see Purpura), 854. 

Wet dressings vs. poultices, 58. 

Wet-nurse, in acute indigestion and diar- 
rhea, 369 ; in gastro-enteric intoxica- 
tion, 358 ; in acute inanition, 221 ; se- 
lection of, 176 ; dangers from syphi- 
litic, 1127. 

Wet-nursing, 176 ; vs. artificial feeding, 
168 ; indications for, 169 ; disadvan- 
tages of, 166. 

Wheal, in urticaria, 934. 

W T hey, 162 ; wine, 162. 

White-swelling of knee, 916. . 

Whooping cough (see Pertussis), 1003. 

Widal's test, in typhoid fever, 1064. 

Worms, intestinal, 427 ; tape-, 424 ; 
round-, 425 ; thread-, 427. 

Wrist, enlarged epiphyses in rickets, 253. 

Wry-neck (see Torticollis), 703. 

X-ray, in empyema, 565 ; in gastric re- 
tention, 324 ; in osteogenesis imper- 
fecta, 896 ; in osteoperiostitis, 1120 ; in 
pneumonia, 537, 565 ; in syphilitic dac- 
tylitis, 1117 ; in syphilitic osteo- 
periostitis, 1115. 

Zoolak, 161. 



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